Healthcare Provider Details

I. General information

NPI: 1821097940
Provider Name (Legal Business Name): C. DICOVSKY MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 BROADWAY
PATERSON NJ
07514-1421
US

IV. Provider business mailing address

681 BROADWAY
PATERSON NJ
07514-1421
US

V. Phone/Fax

Practice location:
  • Phone: 973-278-1000
  • Fax: 973-278-1709
Mailing address:
  • Phone: 973-278-1000
  • Fax: 973-278-1709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number064703
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number024361
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number059094
License Number StateNJ

VIII. Authorized Official

Name: TERESA LARES
Title or Position: MANAGER
Credential:
Phone: 973-278-1000