=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043602303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY CARE OF NEW JERSEY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2015
-----------------------------------------------------
Last Update Date | 02/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1042 MAIN ST
-----------------------------------------------------
City | PATERSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07503-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-510-2444
-----------------------------------------------------
Fax | 973-278-2818
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1042 MAIN ST
-----------------------------------------------------
City | PATERSON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07503-2212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-510-2444
-----------------------------------------------------
Fax | 973-278-2818
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MANNAN RAZZAK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 973-510-2444
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MB07428300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------