Provider Demographics
NPI:1699105379
Name:MEADOWLANDS EMERGENCY GROUP PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MEADOWLANDS EMERGENCY GROUP PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ANESTHESIOLOGY
Authorized Official - Prefix:
Authorized Official - First Name:ROMAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:KOSIBOROD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:626-447-0296
Mailing Address - Street 1:PO BOX 826431
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-6431
Mailing Address - Country:US
Mailing Address - Phone:201-392-3210
Mailing Address - Fax:
Practice Address - Street 1:55 MEADOWLANDS PKWY
Practice Address - Street 2:
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-2977
Practice Address - Country:US
Practice Address - Phone:201-392-3210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07566200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty