Healthcare Provider Details

I. General information

NPI: 1417898727
Provider Name (Legal Business Name): ORIGIN MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2026
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 HAMBURG TPKE STE 310
WAYNE NJ
07470-2139
US

IV. Provider business mailing address

189 BERDAN AVE UNIT 171
WAYNE NJ
07470-3233
US

V. Phone/Fax

Practice location:
  • Phone: 973-310-5497
  • Fax: 862-298-0729
Mailing address:
  • Phone: 973-310-5497
  • Fax: 862-298-0729

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: AMIR ISSA
Title or Position: OWNER
Credential:
Phone: 973-310-5497