Provider Demographics
NPI:1164739447
Name:ADVANCED GASTROENTEROLOGY, PA
Entity Type:Organization
Organization Name:ADVANCED GASTROENTEROLOGY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-731-8686
Mailing Address - Street 1:741 NORTHFIELD AVENUE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052
Mailing Address - Country:US
Mailing Address - Phone:973-731-8686
Mailing Address - Fax:973-731-1911
Practice Address - Street 1:741 NORTHFIELD AVENUE
Practice Address - Street 2:SUITE 204
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052
Practice Address - Country:US
Practice Address - Phone:973-731-8686
Practice Address - Fax:973-731-1911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-08
Last Update Date:2010-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA037333207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC61297Medicare UPIN