Provider Demographics
NPI:1871804534
Name:MEDICAL AND GERATRIC ASSOCIATE PC
Entity type:Organization
Organization Name:MEDICAL AND GERATRIC ASSOCIATE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD OF DIRECTORS
Authorized Official - Prefix:DR
Authorized Official - First Name:LORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-747-1684
Mailing Address - Street 1:PO BOX 52
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-0052
Mailing Address - Country:US
Mailing Address - Phone:201-747-1684
Mailing Address - Fax:
Practice Address - Street 1:2239 CENTER AVE
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-6123
Practice Address - Country:US
Practice Address - Phone:201-747-1684
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-28
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07927200207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty