Mim Medical PC

Primary specialty

Psychiatry PhysicianTaxonomy code 2084P0800X

Legal business name

MIM MEDICAL PC

Practice address

11 Mackay Ave
Paramus, NJ 07652-1273

Phone

(201) 587-0380

Fax

(201) 587-0384

NPI assigned

Mar 20, 2008

Last updated

Jul 13, 2009By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Marina N Metelitisin, MD

Title

Owner

Phone

(201) 587-0380

Specialties & licenses 2

Addresses

Other identifiers 1

Locations

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

{
    "created_epoch": "1205971200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1247443200000",
    "number": "1982875662",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "13876 QUEENS BLVD",
            "address_2": "FIRST FLOOR",
            "city": "BRIARWOOD",
            "state": "NY",
            "postal_code": "114352930",
            "telephone_number": "718-850-6345",
            "fax_number": "718-559-4895"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "11 MACKAY AVE",
            "city": "PARAMUS",
            "state": "NJ",
            "postal_code": "076521273",
            "telephone_number": "201-587-0380",
            "fax_number": "201-587-0384"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MIM MEDICAL PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-03-20",
        "last_updated": "2009-07-13",
        "status": "A",
        "authorized_official_last_name": "METELITISIN",
        "authorized_official_first_name": "MARINA",
        "authorized_official_middle_name": "N",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "201-587-0380",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "2084N0400X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Neurology",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LICENSE NUMBER",
            "identifier": "25MA06616900",
            "state": "NJ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 13, 2009; 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.