Provider Demographics
NPI:1316303035
Name:ICONIC WELLNESS SURGICAL SERVICES
Entity type:Organization
Organization Name:ICONIC WELLNESS SURGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:SADYK
Authorized Official - Middle Name:
Authorized Official - Last Name:FAYZULAYEV
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:201-444-1645
Mailing Address - Street 1:139 HARRISTOWN RD
Mailing Address - Street 2:STE 205
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-3312
Mailing Address - Country:US
Mailing Address - Phone:201-444-1645
Mailing Address - Fax:201-444-1787
Practice Address - Street 1:139 HARRISTOWN RD
Practice Address - Street 2:STE 205
Practice Address - City:GLEN ROCK
Practice Address - State:NJ
Practice Address - Zip Code:07452-3312
Practice Address - Country:US
Practice Address - Phone:201-444-1645
Practice Address - Fax:201-444-1787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00262900363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty