Provider Demographics
NPI:1588108062
Name:PANACEA ID HEALTH LLC
Entity type:Organization
Organization Name:PANACEA ID HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNETA
Authorized Official - Middle Name:V
Authorized Official - Last Name:GOLUBCHIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-464-3636
Mailing Address - Street 1:20 OVERLOOK RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07046-1509
Mailing Address - Country:US
Mailing Address - Phone:908-464-3636
Mailing Address - Fax:908-464-6711
Practice Address - Street 1:20 OVERLOOK RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07046-1509
Practice Address - Country:US
Practice Address - Phone:908-464-3636
Practice Address - Fax:908-464-6711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08153500207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty