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General NPI Number Information
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NPI Number | 1699105379
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Entity Type | Organization
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Legal Business Name | MEADOWLANDS EMERGENCY GROUP PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 11/18/2013
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Last Update Date | 04/09/2014
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Provider Practice Location Address
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Address Line | 55 MEADOWLANDS PKWY
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City | SECAUCUS
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State | NJ
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Zip | 07094-2977
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Country | US
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Telephone | 201-392-3210
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 826431
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City | PHILADELPHIA
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State | PA
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Zip | 19182-6431
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Country | US
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Telephone | 201-392-3210
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Fax |
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Authorized Official
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Title or Position | ANESTHESIOLOGY
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Name | ROMAN N KOSIBOROD
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Credential | D.O.
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Telephone | 626-447-0296
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 25MB07566200
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License Number State | NJ
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