Provider Demographics
NPI:1518394519
Name:EBERHARDT, MICHAEL RALPH (MS, PA-C, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RALPH
Last Name:EBERHARDT
Suffix:
Gender:M
Credentials:MS, PA-C, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 JACK MARTIN BLVD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724-7776
Mailing Address - Country:US
Mailing Address - Phone:732-840-7500
Mailing Address - Fax:732-840-7500
Practice Address - Street 1:457 JACK MARTIN BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-7776
Practice Address - Country:US
Practice Address - Phone:732-840-7500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-04
Last Update Date:2021-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00660700363A00000X, 363AS0400X
NJ25MT001849002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer