Provider Demographics
NPI:1063634459
Name:CLOSTER MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:CLOSTER MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VALURE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHURCHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-768-3900
Mailing Address - Street 1:200 CLOSTER DOCK RD
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-1928
Mailing Address - Country:US
Mailing Address - Phone:201-768-3900
Mailing Address - Fax:201-768-3840
Practice Address - Street 1:200 CLOSTER DOCK RD
Practice Address - Street 2:
Practice Address - City:CLOSTER
Practice Address - State:NJ
Practice Address - Zip Code:07624-1928
Practice Address - Country:US
Practice Address - Phone:201-768-3900
Practice Address - Fax:201-768-3840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7261403Medicaid
NJ7261403Medicaid