Provider Demographics
NPI:1063739829
Name:INTEGRATIVE FUNCTIONAL MEDICINE ASSOCIATES LLC
Entity type:Organization
Organization Name:INTEGRATIVE FUNCTIONAL MEDICINE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:JODI
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-967-8425
Mailing Address - Street 1:41 WATCHUNG PLZ
Mailing Address - Street 2:SUITE 345
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-4117
Mailing Address - Country:US
Mailing Address - Phone:201-967-8425
Mailing Address - Fax:201-967-8443
Practice Address - Street 1:292 BLOOMFIELD AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3624
Practice Address - Country:US
Practice Address - Phone:973-928-8909
Practice Address - Fax:201-967-8425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-03
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA072959002081P0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P0004XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSpinal Cord Injury MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ005466Medicaid