Provider Demographics
NPI:1316036015
Name:RARITAN BAY MEDICAL CENTER PROFESSIONAL SERVICES
Entity Type:Organization
Organization Name:RARITAN BAY MEDICAL CENTER PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-293-2314
Mailing Address - Street 1:PO BOX 48270
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07101-4800
Mailing Address - Country:US
Mailing Address - Phone:201-818-9118
Mailing Address - Fax:
Practice Address - Street 1:2045 ROUTE 35 SOUTH
Practice Address - Street 2:
Practice Address - City:SAYREVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08872
Practice Address - Country:US
Practice Address - Phone:732-316-4951
Practice Address - Fax:732-316-0215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07930600174400000X
NJ25MA05842900174400000X
NJ25MA02674500174400000X
NJ25MA04981500174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTAX IDENTIFICATION NUMBER