Provider Demographics
NPI:1124103973
Name:CLIFTON WALLINGTON MEDICAL GROPU
Entity type:Organization
Organization Name:CLIFTON WALLINGTON MEDICAL GROPU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANANGER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVIRGILIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-473-4624
Mailing Address - Street 1:1033 CLIFTON AVE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-3517
Mailing Address - Country:US
Mailing Address - Phone:973-473-4624
Mailing Address - Fax:973-476-4547
Practice Address - Street 1:1033 CLIFTON AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-3517
Practice Address - Country:US
Practice Address - Phone:973-473-4624
Practice Address - Fax:973-476-4547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA05999500174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty