Healthcare Provider Details

I. General information

NPI: 1891880019
Provider Name (Legal Business Name): TRISTATE MEDICAL ASSOCIATES, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 09/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

642 BROAD ST 2ND FLOOR, SUITE 9
CLIFTON NJ
07013-1615
US

IV. Provider business mailing address

PO BOX 163
ROSELAND NJ
07068-0163
US

V. Phone/Fax

Practice location:
  • Phone: 973-614-9500
  • Fax: 973-614-8200
Mailing address:
  • Phone: 973-614-9500
  • Fax: 973-614-8200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMA072674
License Number StateNJ

VIII. Authorized Official

Name: MRS. MARINA BELOZERSKY
Title or Position: OFFICE MANAGER
Credential: CPA
Phone: 973-614-9500