Healthcare Provider Details

I. General information

NPI: 1295894038
Provider Name (Legal Business Name): ASSOCIATES IN KIDNEY DISEASE & HYPERTENSION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2006
Last Update Date: 01/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2177 OAK TREE RD SUITE 204
EDISON NJ
08820-1082
US

IV. Provider business mailing address

17 ANNA LN
EDISON NJ
08820-1503
US

V. Phone/Fax

Practice location:
  • Phone: 908-769-4735
  • Fax: 908-769-4736
Mailing address:
  • Phone: 908-769-4735
  • Fax: 908-769-4736

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number25MA07583200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0076538
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: DR. SAMIR SUTARIA
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 908-769-4735