Healthcare Provider Details

I. General information

NPI: 1346365905
Provider Name (Legal Business Name): PROSPECT MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 PROSPECT AVE
HACKENSACK NJ
07601-2570
US

IV. Provider business mailing address

277 PROSPECT AVE UNIT LG
HACKENSACK NJ
07601-2512
US

V. Phone/Fax

Practice location:
  • Phone: 201-968-1881
  • Fax: 201-968-0330
Mailing address:
  • Phone: 201-968-1881
  • Fax: 201-968-0330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA06930200
License Number StateNJ

VII. Legacy identifiers

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

# 1
Identifier201403274
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerTAX ID

VIII. Authorized Official

Name: DR. SHAN SIVENDRA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 201-968-1881