NPIMap

Organization Active NPI

Evergreen Medical Group PC

  • Physical Medicine & Rehabilitation Physician
  • River Edge, NJ
National Provider Identifier
1295516409
Registry record updated Feb 11, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical Medicine & Rehabilitation PhysicianTaxonomy code 208100000X
Legal business name
EVERGREEN MEDICAL GROUP PC
Practice address
887 Kinderkamack Rd Ste 2
River Edge, NJ 07661-2307
Phone
(201) 464-0860
Fax
(888) 440-2752
NPI assigned
Oct 12, 2023
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 11, 2025

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

Authorized official

Name
Grigory Shtender, MDNPI 1952316614
Title
Owner
Phone
(201) 791-7771

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 10

Specialty (taxonomy)CodeLicenseStatePrimary
ChiropractorGroup: 193200000X MULTI-SPECIALTY GROUP 111N00000X
Internal Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207R00000X
Physical Medicine & Rehabilitation PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208100000X Primary
Vascular Surgery PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2086S0129X
Foot & Ankle Surgery PodiatristGroup: 193200000X MULTI-SPECIALTY GROUP 213ES0103X
Physical TherapistGroup: 193200000X MULTI-SPECIALTY GROUP 225100000X
Adult Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LA2200X
Family Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LF0000X
Gerontology Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LG0600X
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X

Addresses

Primary practice location

887 Kinderkamack Rd Ste 2
River Edge, NJ 07661-2307

Mailing address

887 Kinderkamack Rd Ste 2
River Edge, NJ 07661-2307
Phone (201) 464-0860

Other practice location 1

31-00 Broadway
Fair Lawn, NJ 07410-3963
Phone (201) 791-7771

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NJ

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240805002666 NJ Part B Supplier - Clinic/Group Practice 2769929082 Receives reassigned benefits from 14 practitioners
Practice locations: Fair Lawn, NJ; River Edge, NJ

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
31D2321162Evergreen Medical Group887 Kinderkamack Road, River Edge, NJ 07661Certificate of waiverMar 30, 2027

National Provider Directory

National Provider Directory

Locations

887 Kinderkamack Rd
Ste 2
River Edge, NJ 07661
Phone (201) 464-0860

Practitioners & affiliated clinicians

Practitioners 18

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 18

NPI Registry JSON

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

{
    "created_epoch": "1697068800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1739232000000",
    "number": "1295516409",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "887 KINDERKAMACK RD STE 2",
            "city": "RIVER EDGE",
            "state": "NJ",
            "postal_code": "076612307",
            "telephone_number": "201-464-0860"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "887 KINDERKAMACK RD STE 2",
            "city": "RIVER EDGE",
            "state": "NJ",
            "postal_code": "076612307",
            "telephone_number": "201-464-0860",
            "fax_number": "888-440-2752"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "31-00 Broadway",
            "address_purpose": "LOCATION",
            "city": "Fair Lawn",
            "state": "NJ",
            "postal_code": "074103963",
            "country_code": "US",
            "telephone_number": "201-791-7771",
            "fax_number": "201-350-8614",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "EVERGREEN MEDICAL GROUP PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-10-12",
        "last_updated": "2025-02-11",
        "certification_date": "2025-02-11",
        "status": "A",
        "authorized_official_last_name": "SHTENDER",
        "authorized_official_first_name": "GRIGORY",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "201-791-7771",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "111N00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Chiropractor",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Internal Medicine",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "208100000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physical Medicine & Rehabilitation",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "2086S0129X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Surgery, Vascular Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "213ES0103X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Podiatrist, Foot & Ankle Surgery",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physical Therapist",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LA2200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Adult Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Family",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LG0600X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Gerontology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in River Edge, NJ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 11, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.