Provider Demographics
NPI:1588706725
Name:XL-MED PC
Entity type:Organization
Organization Name:XL-MED PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:LISHKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-475-1005
Mailing Address - Street 1:17-17 GREENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FAIR LAWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07410-4533
Mailing Address - Country:US
Mailing Address - Phone:201-475-1005
Mailing Address - Fax:201-475-1009
Practice Address - Street 1:25-15 FAIR LAWN AVE
Practice Address - Street 2:
Practice Address - City:FAIR LAWN
Practice Address - State:NJ
Practice Address - Zip Code:07410-3434
Practice Address - Country:US
Practice Address - Phone:201-475-1005
Practice Address - Fax:201-475-1009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA67105261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8503702Medicaid
NJ049268Medicare ID - Type Unspecified
NJ8503702Medicaid