Healthcare Provider Details

I. General information

NPI: 1952769960
Provider Name (Legal Business Name): GERIATRICS AND INTERNAL MEDICINE ASSOCIATES OF NORTHEAST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 02/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W RIDGEWOOD AVE SUITE 203
PARAMUS NJ
07652-2359
US

IV. Provider business mailing address

1 W RIDGEWOOD AVE SUITE 203
PARAMUS NJ
07652-2359
US

V. Phone/Fax

Practice location:
  • Phone: 347-308-4561
  • Fax:
Mailing address:
  • Phone: 347-308-4561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSANTHI GUNADASA
Title or Position: OWNER
Credential: MD, MBBS
Phone: 347-308-4561