Provider Demographics
NPI:1225105224
Name:ELIZABETH MEDICAL GROUP PA
Entity Type:Organization
Organization Name:ELIZABETH MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODGOLD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-351-2222
Mailing Address - Street 1:310 W JERSEY ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202-1832
Mailing Address - Country:US
Mailing Address - Phone:908-351-2222
Mailing Address - Fax:908-351-1977
Practice Address - Street 1:310 W JERSEY ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-1832
Practice Address - Country:US
Practice Address - Phone:908-351-2222
Practice Address - Fax:908-351-1977
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2935007Medicaid
001034Medicare ID - Type Unspecified