Provider Demographics
NPI:1033219357
Name:RARITAN BAY MEDICAL CENTER PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:RARITAN BAY MEDICAL CENTER PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-293-2314
Mailing Address - Street 1:PO BOX 48270
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07101-4800
Mailing Address - Country:US
Mailing Address - Phone:201-818-9118
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-3012
Practice Address - Country:US
Practice Address - Phone:732-324-5348
Practice Address - Fax:732-324-4811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05255000174400000X
NJ25MA05696500174400000X
NJ25MA05746900174400000X
NJ25MA05873200174400000X
NJ25MA02710200174400000X
NJ25MA03479600174400000X
NJ25MA04327900174400000X
NJ25MA03121400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTAX IDENTIFICATION NUMBER