Provider Demographics
NPI:1184996332
Name:590 MEDICAL, LLC
Entity type:Organization
Organization Name:590 MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:VERNON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:201-420-1165
Mailing Address - Street 1:590 NEWARK AVE
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07306-2302
Mailing Address - Country:US
Mailing Address - Phone:201-420-1165
Mailing Address - Fax:201-420-6893
Practice Address - Street 1:590 NEWARK AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-2302
Practice Address - Country:US
Practice Address - Phone:201-420-1165
Practice Address - Fax:201-420-6893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-03
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ111N00000X, 204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG33081Medicare UPIN