Provider Demographics
NPI:1003977489
Name:MIDDLESEX MONMOUTH GASTROENTEROLOGY
Entity Type:Organization
Organization Name:MIDDLESEX MONMOUTH GASTROENTEROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBARD
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:732-577-1999
Mailing Address - Street 1:222 SCHANCK RD STE 302
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2974
Mailing Address - Country:US
Mailing Address - Phone:732-577-1999
Mailing Address - Fax:732-845-5356
Practice Address - Street 1:222 SCHANCK RD STE 302
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2974
Practice Address - Country:US
Practice Address - Phone:732-577-1999
Practice Address - Fax:732-845-5356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207L00000X
207RG0100X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ583237OtherMEDICARE GROUP ID- MIDDLESEX COUNTY OFFICES
NJ31D0124927OtherCLIA
NJ7110901Medicaid
NJ=========OtherTAX ID
NJ31D0124927OtherCLIA