Organization
PROSPECT MEDICAL PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SHAN SIVENDRA M.D. (PRESIDENT)
(201) 968-1881
Entity
Organization
Contact information
Practice address
277 PROSPECT AVE, HACKENSACK, NJ 07601-2570
(201) 968-1881
(201) 968-0330
Mailing address
277 PROSPECT AVE, UNIT LG, HACKENSACK, NJ 07601-2512
(201) 968-1881
(201) 968-0330
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
Primary
25MA06930200
NJ
332B00000X
Durable Medical Equipment & Medical Supplies
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
201403274
TAX ID
NJ
Enumeration date
03/20/2007
Last updated
08/01/2014
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