Provider Demographics
NPI:1326205659
Name:CENTRASTATE MEDICAL CENTER
Entity Type:Organization
Organization Name:CENTRASTATE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:FAISTL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-294-2540
Mailing Address - Street 1:20105 BAINBRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-4866
Mailing Address - Country:US
Mailing Address - Phone:732-513-2546
Mailing Address - Fax:
Practice Address - Street 1:1001 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2579
Practice Address - Country:US
Practice Address - Phone:732-294-2540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0005XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Family Planning Facility