# TRI STATE HEALTH AND WELLNESS MEDICAL CARE CENTER PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1154661593
- **Authorized official:** DR. ALEKSANDER MARTIROSOV D.O. (MEDICAL DIRECTRO)
- **Authorized official phone:** (201) 791-7771

## Contact information

- **Practice address:** 31-00 BROADWAY 1ST FLOOR, FAIR LAWN, NJ 07410
- **Practice address phone:** (201) 741-5891
- **Practice address fax:** (201) 791-7337
- **Mailing address:** 31-00 BROADWAY, FAIR LAWN, NJ 07410-3963
- **Mailing address phone:** (201) 741-5891
- **Mailing address fax:** (201) 791-7337

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207KA0200X | Allergy Physician | 25MB06860100 | NJ | — |
| 207QA0401X | Addiction Medicine (Family Medicine) Physician | 25MB06860100 | NJ | — |
| 207QA0505X | Adult Medicine Physician | 25MB06860100 | NJ | — |
| 207RA0000X | Adolescent Medicine (Internal Medicine) Physician | 25MB06860100 | NJ | — |
| 207RA0401X | Addiction Medicine (Internal Medicine) Physician | 25MB06860100 | NJ | — |
| 207RC0000X | Cardiovascular Disease Physician | 25MB06860100 | NJ | — |
| 207RE0101X | Endocrinology, Diabetes & Metabolism Physician | 25MB06860100 | NJ | — |
| 207RI0011X | Interventional Cardiology Physician | 25MB06860100 | NJ | — |
| 207RS0010X | Sports Medicine (Internal Medicine) Physician | 25MB06860100 | NJ | — |
| 208D00000X | General Practice Physician | 25MB06860100 | NJ | Yes |

## Other

- **Enumeration date:** 02/21/2013
- **Last updated:** 02/21/2013

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 7912404 | — | NJ |