Basic Information
| Provider Information | |||||||||
| NPI: | 1811009657 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MRAVCAK | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ROUTE 46 E STE 450 | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070041583 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735593700 | ||||||||
| FaxNumber: | 9735598650 | ||||||||
| Practice Location | |||||||||
| Address1: | 127 MONTGOMERY ST | ||||||||
| Address2: | |||||||||
| City: | JERSEY CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 073023616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014317200 | ||||||||
| FaxNumber: | 2015260474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MA07499300 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0078581 | 05 | NJ | MEDICAID |