Provider Demographics
NPI:1487851903
Name:RIDGEWOOD INFECTIOUS DISEASE ASSOCIATES, PA
Entity Type:Organization
Organization Name:RIDGEWOOD INFECTIOUS DISEASE ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:G
Authorized Official - Last Name:KNACKMUHS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-447-6468
Mailing Address - Street 1:141 DAYTON ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-4496
Mailing Address - Country:US
Mailing Address - Phone:201-447-6468
Mailing Address - Fax:201-447-3189
Practice Address - Street 1:141 DAYTON ST
Practice Address - Street 2:SUITE 201
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-4496
Practice Address - Country:US
Practice Address - Phone:201-447-6468
Practice Address - Fax:201-447-3189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03896800174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1084470OtherAETNA HMO GROUP #
NJ7117748OtherAETNA PPO GROUP #
NJ3240509Medicaid
NJCM1037OtherRAILROAD MCR GROUP #
NJCM1037OtherRAILROAD MCR GROUP #
NJ569689Medicare PIN