Healthcare Provider Details

I. General information

NPI: 1134889975
Provider Name (Legal Business Name): HIGH MOUNTAIN MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2021
Last Update Date: 12/21/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 CEDAR AVE
HACKENSACK NJ
07601-2956
US

IV. Provider business mailing address

164 CEDAR AVE
HACKENSACK NJ
07601-2956
US

V. Phone/Fax

Practice location:
  • Phone: 312-852-0912
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VII. Legacy identifiers

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

# 1
Identifier1952794489
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerMEDICINE

VIII. Authorized Official

Name: ALI TABARROKI
Title or Position: PHYSICIAN
Credential: MD
Phone: 312-852-0912