Provider Demographics
NPI:1124533443
Name:PETROVANI FAMILY MEDICINE PLLC
Entity type:Organization
Organization Name:PETROVANI FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:PETROVANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-425-4888
Mailing Address - Street 1:10 PARKER PL
Mailing Address - Street 2:
Mailing Address - City:FORDS
Mailing Address - State:NJ
Mailing Address - Zip Code:08863-2400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:646-374-4940
Practice Address - Street 1:10 PARKER PL
Practice Address - Street 2:
Practice Address - City:FORDS
Practice Address - State:NJ
Practice Address - Zip Code:08863
Practice Address - Country:US
Practice Address - Phone:646-759-5453
Practice Address - Fax:646-374-4940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195910207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty