Provider Demographics
NPI:1467584284
Name:CLOSTER INTERNAL MEDICINE, P.C.
Entity Type:Organization
Organization Name:CLOSTER INTERNAL MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:SOO
Authorized Official - Middle Name:G
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-784-3600
Mailing Address - Street 1:15 VER VALEN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-2636
Mailing Address - Country:US
Mailing Address - Phone:201-784-3600
Mailing Address - Fax:201-784-5677
Practice Address - Street 1:15 VERVALEN ST
Practice Address - Street 2:
Practice Address - City:CLOSTER
Practice Address - State:NJ
Practice Address - Zip Code:07624-2635
Practice Address - Country:US
Practice Address - Phone:201-784-3600
Practice Address - Fax:201-784-5677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07426600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9116508Medicaid
NJ067639Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NJH51413Medicare UPIN