Provider Demographics
NPI:1891865556
Name:TRI TOWN MEDICAL CENTER
Entity type:Organization
Organization Name:TRI TOWN MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:KAWAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-942-3200
Mailing Address - Street 1:PO BOX 3400
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07474-3400
Mailing Address - Country:US
Mailing Address - Phone:973-942-3200
Mailing Address - Fax:973-942-2901
Practice Address - Street 1:160 HALEDON AVE
Practice Address - Street 2:
Practice Address - City:PROSPECT PARK
Practice Address - State:NJ
Practice Address - Zip Code:07508-2051
Practice Address - Country:US
Practice Address - Phone:973-942-3200
Practice Address - Fax:973-942-2901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06054400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2626509001OtherAMERIHEALTH GROUP #
NJ=========OtherTAX ID#