Healthcare Provider Details

I. General information

NPI: 1427064203
Provider Name (Legal Business Name): AMARNATH AVANCHA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 GREGORY AVE. UNIT 102
PASSAIC NJ
07055-4856
US

IV. Provider business mailing address

124 GREGORY AVE UNIT 102
PASSAIC NJ
07055-4856
US

V. Phone/Fax

Practice location:
  • Phone: 973-777-1132
  • Fax: 973-458-9850
Mailing address:
  • Phone: 973-777-1132
  • Fax: 973-458-9850

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMA058773
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License NumberMA058773
License Number StateNJ

VIII. Authorized Official

Name: DR. AMARNATH AVANCHA
Title or Position: PRESIDENT
Credential: MD,FACC
Phone: 973-777-1132