Provider Demographics
NPI:1366612178
Name:MAHWAH MEDICAL
Entity type:Organization
Organization Name:MAHWAH MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:R
Authorized Official - Last Name:LESLIE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:201-529-0033
Mailing Address - Street 1:10 FRANKLIN TPKE
Mailing Address - Street 2:
Mailing Address - City:MAHWAH
Mailing Address - State:NJ
Mailing Address - Zip Code:07430-1304
Mailing Address - Country:US
Mailing Address - Phone:201-529-0033
Mailing Address - Fax:201-529-5913
Practice Address - Street 1:10 FRANKLIN TPKE
Practice Address - Street 2:
Practice Address - City:MAHWAH
Practice Address - State:NJ
Practice Address - Zip Code:07430-1304
Practice Address - Country:US
Practice Address - Phone:201-529-0033
Practice Address - Fax:201-529-5913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB42681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD18560Medicare UPIN