Healthcare Provider Details

I. General information

NPI: 1457080178
Provider Name (Legal Business Name): PLATINUM PROVIDERS GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1418 NEW RD STE 1
NORTHFIELD NJ
08225-1179
US

IV. Provider business mailing address

2106 NEW RD STE F2
LINWOOD NJ
08221-1053
US

V. Phone/Fax

Practice location:
  • Phone: 609-796-7969
  • Fax: 609-642-2663
Mailing address:
  • Phone: 609-796-7969
  • Fax: 609-642-2663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ATHANASIOS G. PAPASTAMELOS
Title or Position: MANAGING MEMBER
Credential: DO
Phone: 609-469-1585