Provider Demographics
NPI:1508050139
Name:PROGRESSIVE PODIATRY OF NORTH JERSEY
Entity Type:Organization
Organization Name:PROGRESSIVE PODIATRY OF NORTH JERSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:JEANETTE
Authorized Official - Last Name:GEHEGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-840-7373
Mailing Address - Street 1:725 RIVER RD
Mailing Address - Street 2:SUITE 201-A
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1171
Mailing Address - Country:US
Mailing Address - Phone:201-840-7373
Mailing Address - Fax:201-840-7383
Practice Address - Street 1:725 RIVER RD
Practice Address - Street 2:SUITE 201-A
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1171
Practice Address - Country:US
Practice Address - Phone:201-840-7373
Practice Address - Fax:201-840-7383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00272100213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1508050139OtherNPI
NJ6481920001OtherMEDICARE/CMS DME (PTAN)
NJ6481920001Medicare NSC