Provider Demographics
NPI:1295860773
Name:EDISON NEUROLOGIC ASSOCIATES
Entity Type:Organization
Organization Name:EDISON NEUROLOGIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARANOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-757-6633
Mailing Address - Street 1:34-36 PROGRESS ST
Mailing Address - Street 2:SUITE B-3
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-1197
Mailing Address - Country:US
Mailing Address - Phone:908-757-6633
Mailing Address - Fax:908-757-3912
Practice Address - Street 1:34-36 PROGRESS ST
Practice Address - Street 2:SUITE B-3
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08820-1197
Practice Address - Country:US
Practice Address - Phone:908-757-6633
Practice Address - Fax:908-757-3912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3084906Medicaid
NJ576476Medicare ID - Type UnspecifiedGROUP PROVIDER #