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General NPI Number Information
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NPI Number | 1053887596
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Entity Type | Organization
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Legal Business Name | VANCE MEDICAL GROUP
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Dates
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Enumeration Date | 10/23/2018
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Last Update Date | 10/23/2018
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Provider Practice Location Address
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Address Line | 703 MAIN ST
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City | PATERSON
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State | NJ
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Zip | 07503-2621
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Country | US
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Telephone | 973-754-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 98 GEORGE ST
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City | TENAFLY
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State | NJ
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Zip | 07670-2011
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | AUTH REP
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Name | SOURAV SEN
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Credential | MD
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Telephone | 973-653-8076
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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