Healthcare Provider Details

I. General information

NPI: 1851123004
Provider Name (Legal Business Name): AVALON MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2024
Last Update Date: 08/16/2024
Certification Date: 08/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 CLIFTON AVE STE 209
CLIFTON NJ
07013-3642
US

IV. Provider business mailing address

1135 CLIFTON AVE STE 209
CLIFTON NJ
07013-3642
US

V. Phone/Fax

Practice location:
  • Phone: 862-336-9696
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code246XC2903X
TaxonomyVascular Specialist/Technologist Cardiovascular
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: ARTHUR KOSTANIAN
Title or Position: MEMBER/OWNER
Credential:
Phone: 718-838-0640