Provider Demographics
NPI:1417998303
Name:OLD HOOK MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:OLD HOOK MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTECILLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-666-3900
Mailing Address - Street 1:452 OLD HOOK RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:EMERSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07630-1381
Mailing Address - Country:US
Mailing Address - Phone:201-666-3900
Mailing Address - Fax:201-261-0505
Practice Address - Street 1:452 OLD HOOK RD
Practice Address - Street 2:2ND FLOOR
Practice Address - City:EMERSON
Practice Address - State:NJ
Practice Address - Zip Code:07630-1381
Practice Address - Country:US
Practice Address - Phone:201-666-3900
Practice Address - Fax:201-261-0505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1092980207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CG1156OtherRAIL ROAD MEDICARE
NJ6720100001Medicare NSC
NJ000991Medicare PIN
NJ072605Medicare PIN