MEDICARE: ROSS TYRONE JENSEN LAVINE

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	390200000X	Student in an Organized Health Care Education/Training Program
2	207RC0200X	Critical Care Medicine (Internal Medicine) Physician	2026-00125	NC
3	207R00000X	Internal Medicine Physician	25MA12040000	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902422553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROSS TYRONE JENSEN LAVINE

Provider Business Mailing Address
First Line	:	350 ENGLE ST DEPT OF
Second Line	:
City	:	ENGLEWOOD
State	:	NJ
Zip	:	07631-1808
Country	:	US
Telephone Number	:	201-894-3143
Fax Number	:

Provider Business Practice Location Address
First Line	:	350 ENGLE ST DEPT OF
Second Line	:
City	:	ENGLEWOOD
State	:	NJ
Zip	:	07631-1808
Country	:	US
Telephone Number	:	201-894-3143
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2020
Last Update Date	:	03/10/2026

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