=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134563836
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IRVINGTON PRIMARY CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2013
-----------------------------------------------------
Last Update Date | 02/17/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 UNION AVE SUITE 605
-----------------------------------------------------
City | IRVINGTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07111-3262
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-388-2181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 MAIDA RD
-----------------------------------------------------
City | EDISON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08820-2530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-388-2181
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OFFICE MANAGER
-----------------------------------------------------
Name | TAZZEEN ASHRAF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 732-388-2181
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------