Healthcare Provider Details

I. General information

NPI: 1639408461
Provider Name (Legal Business Name): AVICENNA MEDICAL ARTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2009
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 TENNENT RD SUITE 104
MANALAPAN NJ
07726-3163
US

IV. Provider business mailing address

PO BOX 302
MANALAPAN NJ
07726-0302
US

V. Phone/Fax

Practice location:
  • Phone: 646-522-3664
  • Fax: 732-831-6171
Mailing address:
  • Phone: 646-522-3664
  • Fax: 646-522-3664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number25MA08792700
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA08792700
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number25MA08792700
License Number StateNJ

VIII. Authorized Official

Name: DR. ALEXANDER VEDER
Title or Position: OWNER
Credential: M.D
Phone: 646-522-3664