Healthcare Provider Details

I. General information

NPI: 1477161172
Provider Name (Legal Business Name): TIERRA MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2020
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

831 MAIN AVE
PASSAIC NJ
07055-8400
US

IV. Provider business mailing address

831 MAIN AVE
PASSAIC NJ
07055-8400
US

V. Phone/Fax

Practice location:
  • Phone: 862-249-1333
  • Fax: 844-892-1555
Mailing address:
  • Phone: 215-847-2929
  • Fax: 844-892-1555

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 Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL FRIDMAN
Title or Position: OWNER
Credential:
Phone: 215-847-2929