MEDICARE: MEDICAL AND GERATRIC ASSOCIATE PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	25MA07927200	NJ

General Provider Information

NPI Number	:	1871804534
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL AND GERATRIC ASSOCIATE PC

Provider Business Mailing Address
First Line	:	PO BOX 52
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-0052
Country	:	US
Telephone Number	:	201-747-1684
Fax Number	:

Provider Business Practice Location Address
First Line	:	2239 CENTER AVE
Second Line	:
City	:	FORT LEE
State	:	NJ
Zip	:	07024-6123
Country	:	US
Telephone Number	:	201-747-1684
Fax Number	:

Authorized Official
Title or Position	:	BOARD OF DIRECTORS
Name	:	DR. LORIS MANSOUR
Credential	:	M.D
Telephone Number	:	201-747-1684

Provider Enumeration Date	:	06/28/2010
Last Update Date	:	06/28/2010

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