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General NPI Number Information
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NPI Number | 1639408461
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Entity Type | Organization
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Legal Business Name | AVICENNA MEDICAL ARTS, PLLC
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Dates
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Enumeration Date | 12/07/2009
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Last Update Date | 03/03/2014
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Provider Practice Location Address
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Address Line | 660 TENNENT RD SUITE 104
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City | MANALAPAN
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State | NJ
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Zip | 07726-3163
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Country | US
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Telephone | 646-522-3664
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Fax | 732-831-6171
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Provider Business Mailing Address
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Address Line | PO BOX 302
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City | MANALAPAN
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State | NJ
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Zip | 07726-0302
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Country | US
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Telephone | 646-522-3664
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Fax | 646-522-3664
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Authorized Official
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Title or Position | OWNER
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Name | DR. ALEXANDER VEDER
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Credential | M.D
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Telephone | 646-522-3664
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 202C00000X
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Taxonomy Name | Independent Medical Examiner Physician
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License Number | 25MA08792700
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 25MA08792700
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License Number State | NJ
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Taxonomy #3
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | 25MA08792700
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License Number State | NJ
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