Healthcare Provider Details

I. General information

NPI: 1295516409
Provider Name (Legal Business Name): EVERGREEN MEDICAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2023
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 KINDERKAMACK RD STE 2
RIVER EDGE NJ
07661-2307
US

IV. Provider business mailing address

887 KINDERKAMACK RD STE 2
RIVER EDGE NJ
07661-2307
US

V. Phone/Fax

Practice location:
  • Phone: 201-464-0860
  • Fax: 888-440-2752
Mailing address:
  • Phone: 201-464-0860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: GRIGORY SHTENDER
Title or Position: OWNER
Credential: MD
Phone: 201-791-7771