Provider Demographics
NPI:1477624088
Name:NORTH HALEDON MEDICAL, PC
Entity Type:Organization
Organization Name:NORTH HALEDON MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRAVECCHIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-942-6005
Mailing Address - Street 1:510 HAMBURG TPKE
Mailing Address - Street 2:WAYNE COMMONS, SUITE 101
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2025
Mailing Address - Country:US
Mailing Address - Phone:973-942-6005
Mailing Address - Fax:973-942-6009
Practice Address - Street 1:510 HAMBURG TPKE
Practice Address - Street 2:WAYNE COMMONS, SUITE 101
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2025
Practice Address - Country:US
Practice Address - Phone:973-942-6005
Practice Address - Fax:973-942-6009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06978600174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2016615002OtherAMERIHEALTH GROUP #
NJ7305262OtherAETNA GROUP #
NJ8644101Medicaid
NJDC3972OtherRAILROAD MDCR GROUP #
NJ7305262OtherAETNA GROUP #
NJDC3972OtherRAILROAD MDCR GROUP #