Basic Information
| Provider Information | |||||||||
| NPI: | 1932639051 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NJ MOBILE MEDICAL, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 67 HOLLY HILL LN STE 102 | ||||||||
| Address2: | |||||||||
| City: | GREENWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068306072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038695515 | ||||||||
| FaxNumber: | 2038695765 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 RIVER AVE STE 103 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087014267 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165958560 | ||||||||
| FaxNumber: | 5166668370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2017 | ||||||||
| LastUpdateDate: | 06/13/2017 | ||||||||
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| AuthorizedOfficialLastName: | GANDELMAN | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
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| AuthorizedOfficialTitleorPosition: | SOLE OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2038695515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MA10120200 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.