# C. DICOVSKY MEDICAL GROUP, LLC

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

## Provider details

- **NPI number:** 1821097940
- **Authorized official:** TERESA LARES (MANAGER)
- **Authorized official phone:** (973) 278-1000

## Contact information

- **Practice address:** 681 BROADWAY, PATERSON, NJ 07514-1421
- **Practice address phone:** (973) 278-1000
- **Practice address fax:** (973) 278-1709
- **Mailing address:** 681 BROADWAY, PATERSON, NJ 07514-1421
- **Mailing address phone:** (973) 278-1000
- **Mailing address fax:** (973) 278-1709

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207R00000X | Internal Medicine Physician | 059094 | NJ | Yes |
| 207R00000X | Internal Medicine Physician | 064703 | NJ | — |
| 207R00000X | Internal Medicine Physician | — | NULL | — |
| 207R00000X | Internal Medicine Physician | — | — | — |
| 2085B0100X | Body Imaging Physician | 024361 | NJ | — |

## Other

- **Enumeration date:** 07/20/2005
- **Last updated:** 03/10/2022