Provider Demographics
NPI:1346231255
Name:PRIMARY CARE ASSOCIATES OF NJ, LLC
Entity Type:Organization
Organization Name:PRIMARY CARE ASSOCIATES OF NJ, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GOLLOUB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-334-9404
Mailing Address - Street 1:329 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:329 MAIN RD
Practice Address - Street 2:
Practice Address - City:MONTVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07045-9729
Practice Address - Country:US
Practice Address - Phone:973-334-9404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA55345207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
086824Medicare ID - Type UnspecifiedPROVIDER NUMBER