Provider Demographics
NPI:1528195468
Name:EDISON MEDICAL NUTRITION CENTER
Entity Type:Organization
Organization Name:EDISON MEDICAL NUTRITION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:BARTON
Authorized Official - Last Name:MENASHE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-906-8866
Mailing Address - Street 1:15 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-3447
Mailing Address - Country:US
Mailing Address - Phone:732-906-8866
Mailing Address - Fax:
Practice Address - Street 1:15 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EDISON
Practice Address - State:NJ
Practice Address - Zip Code:08837-3447
Practice Address - Country:US
Practice Address - Phone:732-906-8866
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB046474261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ047830Medicaid
NJ464013Medicare ID - Type Unspecified
NJ047830Medicaid