Provider Demographics
NPI:1508071002
Name:PAVONIA GASTROENTEROLOGY LLC
Entity Type:Organization
Organization Name:PAVONIA GASTROENTEROLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:STOOPACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-216-3065
Mailing Address - Street 1:PO BOX 8168 FDR STATION
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10150
Mailing Address - Country:US
Mailing Address - Phone:201-216-3065
Mailing Address - Fax:201-499-0250
Practice Address - Street 1:600 PAVONIA AVENUE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306
Practice Address - Country:US
Practice Address - Phone:201-216-3065
Practice Address - Fax:201-499-0250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA05631200207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5037000Medicaid
NJ5037000Medicaid
NJ675621Medicare ID - Type Unspecified