Provider Demographics
NPI:1598464117
Name:IRONBOUND NEWARK MEDICAL PC
Entity type:Organization
Organization Name:IRONBOUND NEWARK MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SIVENDRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-704-6321
Mailing Address - Street 1:332 FERRY ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07105-3548
Mailing Address - Country:US
Mailing Address - Phone:973-589-2171
Mailing Address - Fax:973-589-6225
Practice Address - Street 1:332 FERRY ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105-3548
Practice Address - Country:US
Practice Address - Phone:973-589-2171
Practice Address - Fax:973-589-6225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-02
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8222801Medicaid