=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326117599
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GEETHA HRISHIKESAN MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2006
-----------------------------------------------------
Last Update Date | 08/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 48 FAIRFIELD ST
-----------------------------------------------------
City | MONTCLAIR
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07042-4137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-744-8511
-----------------------------------------------------
Fax | 973-744-6356
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 KARNELL CT
-----------------------------------------------------
City | EDISON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08820-2947
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-548-9667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MA08140200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------