Healthcare Provider Details

I. General information

NPI: 1891865556
Provider Name (Legal Business Name): TRI TOWN MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 HALEDON AVE
PROSPECT PARK NJ
07508-2051
US

IV. Provider business mailing address

PO BOX 3400
WAYNE NJ
07474-3400
US

V. Phone/Fax

Practice location:
  • Phone: 973-942-3200
  • Fax: 973-942-2901
Mailing address:
  • Phone: 973-942-3200
  • Fax: 973-942-2901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA06054400
License Number StateNJ

VIII. Authorized Official

Name: MOHAMED KAWAM
Title or Position: DELEGATED OFFICIAL
Credential: M.D.
Phone: 973-942-3200