Avicenna Medical Group, LLC

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

25MB07627000 Issued in NJ

Legal business name

AVICENNA MEDICAL GROUP, LLC

Practice address

414 Eagle Rock Ave
Suite 307
West Orange, NJ 07052-4224

Phone

(646) 464-3110

NPI assigned

Mar 20, 2013

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Fadi Samaan, MBA, MS

Title

Manager

Phone

(646) 464-3110

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1363737600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1363910400000",
    "number": "1194067959",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "414 EAGLE ROCK AVE",
            "address_2": "SUITE 307",
            "city": "WEST ORANGE",
            "state": "NJ",
            "postal_code": "070524224",
            "telephone_number": "646-464-3110"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "414 EAGLE ROCK AVE",
            "address_2": "SUITE 307",
            "city": "WEST ORANGE",
            "state": "NJ",
            "postal_code": "070524224",
            "telephone_number": "646-464-3110"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "AVICENNA MEDICAL GROUP, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2013-03-20",
        "last_updated": "2013-03-22",
        "status": "A",
        "authorized_official_last_name": "SAMAAN",
        "authorized_official_first_name": "FADI",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "646-464-3110",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "MBA, MS"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Counselor, Mental Health",
            "state": "NJ",
            "license": "25MB07627000",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Mental Health Counselor in West Orange, NJ
• Providers in West Orange, NJ by specialty
• Mental Health Counselor in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 22, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.