Healthcare Provider Details

I. General information

NPI: 1619302288
Provider Name (Legal Business Name): INTERSTATE MULTI-SPECIALTY MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2013
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 MAIN ST
HACKENSACK NJ
07601-7124
US

IV. Provider business mailing address

165 MAIN ST
HACKENSACK NJ
07601-7124
US

V. Phone/Fax

Practice location:
  • Phone: 973-574-2070
  • Fax: 973-574-2090
Mailing address:
  • Phone: 973-574-2070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. ALEXANDR ZAITSEV
Title or Position: PRESIDENT
Credential: M.D.
Phone: 973-574-2070