Healthcare Provider Details

I. General information

NPI: 1407893662
Provider Name (Legal Business Name): MEDICINE AND REHABILITATION PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SYLVAN AVE STE 111
ENGLEWOOD CLIFFS NJ
07632-2705
US

IV. Provider business mailing address

PO BOX 37
FRANKLIN LAKES NJ
07417-0037
US

V. Phone/Fax

Practice location:
  • Phone: 201-568-8500
  • Fax: 201-568-8518
Mailing address:
  • Phone: 201-568-8500
  • Fax: 201-568-8518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberMA63969
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMA67595
License Number StateNJ

VIII. Authorized Official

Name: ANDREI LOGVINENKO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 201-568-8500