Provider Demographics
NPI:1730341801
Name:MARIAN MEDICAL CLINIC PC
Entity type:Organization
Organization Name:MARIAN MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARIAVIDA
Authorized Official - Middle Name:TUPAZ
Authorized Official - Last Name:TECSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-921-9321
Mailing Address - Street 1:116 MILLBURN AVENUE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1919
Mailing Address - Country:US
Mailing Address - Phone:973-921-9321
Mailing Address - Fax:973-921-9323
Practice Address - Street 1:116 MILLBURN AVENUE
Practice Address - Street 2:SUITE 207
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1919
Practice Address - Country:US
Practice Address - Phone:973-921-9321
Practice Address - Fax:973-921-9323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0747600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJP3469886OtherOXFORD
NJ0047031Medicaid
NJ2540897OtherUNITED HEALTHCARE
NJ7135641 3631135OtherAETNA
NJ2K7666OtherHEALTHNET
NJ2540897OtherUNITED HEALTHCARE
NJ=========OtherQUALCARE
NJ=========OtherQUALCARE
NJ2540897OtherUNITED HEALTHCARE