Basic Information
| Provider Information | |||||||||
| NPI: | 1366612178 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAHWAH MEDICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 FRANKLIN TPKE | ||||||||
| Address2: | |||||||||
| City: | MAHWAH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074301304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015290033 | ||||||||
| FaxNumber: | 2015295913 | ||||||||
| Practice Location | |||||||||
| Address1: | 10 FRANKLIN TPKE | ||||||||
| Address2: | |||||||||
| City: | MAHWAH | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074301304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2015290033 | ||||||||
| FaxNumber: | 2015295913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2008 | ||||||||
| LastUpdateDate: | 09/09/2009 | ||||||||
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| AuthorizedOfficialLastName: | LESLIE | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2015290033 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MB42681 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.