Provider Demographics
NPI:1942457023
Name:TRI-STATE HEALTH AND WELLNESS MEDICAL CARE CENTER PC
Entity type:Organization
Organization Name:TRI-STATE HEALTH AND WELLNESS MEDICAL CARE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY PRACTICE
Authorized Official - Prefix:
Authorized Official - First Name:ALEKSANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIROSOV
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:201-791-7771
Mailing Address - Street 1:31-00 BROADWAY
Mailing Address - Street 2:1ST FL.
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-3963
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31-00 BROADWAY
Practice Address - Street 2:1ST FL.
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3963
Practice Address - Country:US
Practice Address - Phone:201-791-7771
Practice Address - Fax:201-791-7337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-20
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service