Provider Demographics
NPI:1619188414
Name:BART E. MAGGIO & PETER K. FINELLI
Entity Type:Organization
Organization Name:BART E. MAGGIO & PETER K. FINELLI
Other - Org Name:SIXTY SEVEN BROADWAY MEDICAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DESANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-796-4444
Mailing Address - Street 1:67 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-1836
Mailing Address - Country:US
Mailing Address - Phone:201-796-4444
Mailing Address - Fax:201-796-4034
Practice Address - Street 1:67 BROADWAY
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407-1836
Practice Address - Country:US
Practice Address - Phone:201-796-4444
Practice Address - Fax:201-796-4034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB018796207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7062206Medicaid
NJ7062206Medicaid