=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508169160
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GMED HEALTHCARE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2010
-----------------------------------------------------
Last Update Date | 12/21/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 842 CLIFTON AVE
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-330-6765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 842 CLIFTON AVE
-----------------------------------------------------
City | CLIFTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07013-1800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-330-6765
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VIKRAM GUPTA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 973-330-6765
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MA08471700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------