Provider Demographics
NPI:1568567238
Name:BRICKTOWN MEDICAL GROUP PA
Entity Type:Organization
Organization Name:BRICKTOWN MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RISS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:732-458-0300
Mailing Address - Street 1:34 LANES MILL RD
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724
Mailing Address - Country:US
Mailing Address - Phone:732-458-0300
Mailing Address - Fax:732-458-8449
Practice Address - Street 1:34 LANES MILL RD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724
Practice Address - Country:US
Practice Address - Phone:732-458-0300
Practice Address - Fax:732-458-8449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty