Healthcare Provider Details

I. General information

NPI: 1235577172
Provider Name (Legal Business Name): HEALTH EAST MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 S DEAN ST
ENGLEWOOD NJ
07631-3514
US

IV. Provider business mailing address

54 S DEAN ST
ENGLEWOOD NJ
07631-3514
US

V. Phone/Fax

Practice location:
  • Phone: 201-871-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number25MA08596900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number25MA08595100
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number25MD00304200
License Number StateNJ

VIII. Authorized Official

Name: ANSON MOISE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 201-871-4000