Provider Demographics
NPI:1467492322
Name:CARL G. QUILLEN, M.D. P.A.
Entity Type:Organization
Organization Name:CARL G. QUILLEN, M.D. P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:G
Authorized Official - Last Name:QUILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-763-2320
Mailing Address - Street 1:2040 MILLBURN AVE
Mailing Address - Street 2:SUITE 405
Mailing Address - City:MAPLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07040-3726
Mailing Address - Country:US
Mailing Address - Phone:973-763-2320
Mailing Address - Fax:973-763-4648
Practice Address - Street 1:2040 MILLBURN AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3726
Practice Address - Country:US
Practice Address - Phone:973-763-2320
Practice Address - Fax:973-763-4648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA34002174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6643302Medicaid
NJC53310Medicare UPIN
NJ429653Medicare ID - Type Unspecified