Healthcare Provider Details

I. General information

NPI: 1982875662
Provider Name (Legal Business Name): MIM MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 07/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 MACKAY AVE
PARAMUS NJ
07652-1273
US

IV. Provider business mailing address

13876 QUEENS BLVD FIRST FLOOR
BRIARWOOD NY
11435-2930
US

V. Phone/Fax

Practice location:
  • Phone: 201-587-0380
  • Fax: 201-587-0384
Mailing address:
  • Phone: 718-850-6345
  • Fax: 718-559-4895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier25MA06616900
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerLICENSE NUMBER

VIII. Authorized Official

Name: MARINA N METELITISIN
Title or Position: OWNER
Credential: MD
Phone: 201-587-0380