Provider Demographics
NPI:1548569361
Name:SAINT PETER'S HEALTHCARE SYSTEM PHYSICIAN ASSOCIATES
Entity Type:Organization
Organization Name:SAINT PETER'S HEALTHCARE SYSTEM PHYSICIAN ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARRICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:STOLDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-745-6651
Mailing Address - Street 1:240 EASTON AVENUE
Mailing Address - Street 2:THIRD FLOOR MANAGED CARE DEPARTMENT
Mailing Address - City:NEW BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08901-1766
Mailing Address - Country:US
Mailing Address - Phone:732-565-5453
Mailing Address - Fax:732-249-9572
Practice Address - Street 1:254 EASTON AVE
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-1766
Practice Address - Country:US
Practice Address - Phone:732-745-6651
Practice Address - Fax:732-745-7938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-18
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0301647Medicaid