Healthcare Provider Details

I. General information

NPI: 1528801024
Provider Name (Legal Business Name): AVICENNA PAIN TREATMENT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2024
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

152 POND DR
TOWNSHIP OF WASHINGTON NJ
07676-5130
US

IV. Provider business mailing address

PO BOX 110055
NUTLEY NJ
07110-0901
US

V. Phone/Fax

Practice location:
  • Phone: 862-333-8935
  • Fax: 201-983-6600
Mailing address:
  • Phone: 862-333-8935
  • Fax: 201-983-6600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ALEXANDER ZHURAVKOV
Title or Position: PRESIDENT
Credential: MD
Phone: 201-906-9279