Provider Demographics
NPI:1598803264
Name:INTERNAL MEDICINE AND GERIATRICS PRACTICE, INC
Entity type:Organization
Organization Name:INTERNAL MEDICINE AND GERIATRICS PRACTICE, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WALEED
Authorized Official - Middle Name:S
Authorized Official - Last Name:LASHIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-253-6000
Mailing Address - Street 1:1414 MAIN AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-2157
Mailing Address - Country:US
Mailing Address - Phone:973-253-6000
Mailing Address - Fax:973-253-6009
Practice Address - Street 1:1414 MAIN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2157
Practice Address - Country:US
Practice Address - Phone:973-253-6000
Practice Address - Fax:973-253-6009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA07809300261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0064394Medicaid
NJ090415Medicare ID - Type Unspecified
NJ0064394Medicaid