Healthcare Provider Details

I. General information

NPI: 1467782904
Provider Name (Legal Business Name): MGM MEDIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2010
Last Update Date: 05/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3215 GATES CT
MORRIS PLAINS NJ
07950-3475
US

IV. Provider business mailing address

3215 GATES CT
MORRIS PLAINS NJ
07950-3475
US

V. Phone/Fax

Practice location:
  • Phone: 203-524-5566
  • Fax:
Mailing address:
  • Phone: 203-524-5566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA087883900
License Number StateNJ

VIII. Authorized Official

Name: BASSEM G HANNA
Title or Position: DIRECTOR
Credential: MD
Phone: 203-524-5566