Provider Demographics
NPI:1215257878
Name:FAMILY MEDICAL GROUP, PC
Entity type:Organization
Organization Name:FAMILY MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ESSAM
Authorized Official - Middle Name:ABDOU
Authorized Official - Last Name:OTHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-436-0022
Mailing Address - Street 1:700 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07208-2310
Mailing Address - Country:US
Mailing Address - Phone:908-436-0022
Mailing Address - Fax:
Practice Address - Street 1:700 N BROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07208-2310
Practice Address - Country:US
Practice Address - Phone:908-436-0022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2010-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06234900251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7077009Medicaid