Provider Demographics
NPI:1104880061
Name:ANDREAS D. ROTSIDES, MD, LLC
Entity type:Organization
Organization Name:ANDREAS D. ROTSIDES, MD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:ROTSIDES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-328-1040
Mailing Address - Street 1:195 US HIGHWAY 46
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MINE HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07803-3163
Mailing Address - Country:US
Mailing Address - Phone:973-328-1040
Mailing Address - Fax:973-328-1544
Practice Address - Street 1:195 US HIGHWAY 46
Practice Address - Street 2:SUITE 200
Practice Address - City:MINE HILL
Practice Address - State:NJ
Practice Address - Zip Code:07803-3163
Practice Address - Country:US
Practice Address - Phone:973-328-1040
Practice Address - Fax:973-328-1544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-16
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05010400207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0077241Medicaid
NJ2352899001OtherAMERIHEALTH GROUP ID
NJDG4164OtherRAILROAD MEDICARE GRP
NJ2352899001OtherAMERIHEALTH GROUP ID
NJ=========OtherPRACTICE TIN
NJ0077241Medicaid