Provider Demographics
NPI:1679865604
Name:HIGHLAND MEDICAL GROUP OF NEW JERSEY, PC
Entity type:Organization
Organization Name:HIGHLAND MEDICAL GROUP OF NEW JERSEY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEXANDR
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAITSEV
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-574-2070
Mailing Address - Street 1:PO BOX 4125
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07474-4125
Mailing Address - Country:US
Mailing Address - Phone:973-574-2070
Mailing Address - Fax:973-574-2090
Practice Address - Street 1:126 STATE ST
Practice Address - Street 2:FL 1
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-5448
Practice Address - Country:US
Practice Address - Phone:973-574-2070
Practice Address - Fax:973-574-2090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-10
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07388400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ225619Medicare UPIN