Healthcare Provider Details

I. General information

NPI: 1992899850
Provider Name (Legal Business Name): THE SAMRA GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PERRINE RD SUITE 331
OLD BRIDGE NJ
08857-2871
US

IV. Provider business mailing address

300 PERRINE RD SUITE 331
OLD BRIDGE NJ
08857-2871
US

V. Phone/Fax

Practice location:
  • Phone: 732-727-8800
  • Fax: 732-727-0955
Mailing address:
  • Phone: 732-727-8800
  • Fax: 732-727-0955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent 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
Identifier0480304
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier0086720
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 3
Identifier0152099
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 4
Identifier0152081
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 5
Identifier3155501
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: MUNISA NAZIROVA
Title or Position: OFFICE MANAGER
Credential:
Phone: 732-739-2100