Provider Demographics
NPI:1104008374
Name:GARDEN STATE BARIATRICS & WELLNESS CENTER,LLC
Entity Type:Organization
Organization Name:GARDEN STATE BARIATRICS & WELLNESS CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:BILOF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-218-1990
Mailing Address - Street 1:225 MILLBURN AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1737
Mailing Address - Country:US
Mailing Address - Phone:973-218-1990
Mailing Address - Fax:
Practice Address - Street 1:225 MILLBURN AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1737
Practice Address - Country:US
Practice Address - Phone:973-218-1990
Practice Address - Fax:973-629-1274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ25MA05641900207QB0002X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Single Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ119260Medicare PIN