Healthcare Provider Details

I. General information

NPI: 1588009740
Provider Name (Legal Business Name): RAISA BAKSHIYEV M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 JACK MARTIN BLVD
BRICK NJ
08724-7732
US

IV. Provider business mailing address

65 JAMES ST
EDISON NJ
08820-3947
US

V. Phone/Fax

Practice location:
  • Phone: 732-836-4504
  • Fax: 732-836-4532
Mailing address:
  • Phone: 732-321-7070
  • Fax: 732-321-7330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number290336
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MA09836100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: