Provider Demographics
NPI:1659601789
Name:DR JM LLC
Entity Type:Organization
Organization Name:DR JM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MABAGOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-279-6537
Mailing Address - Street 1:525 ROUTE 70 EAST
Mailing Address - Street 2:SUITE 1-C
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-4022
Mailing Address - Country:US
Mailing Address - Phone:732-279-6537
Mailing Address - Fax:732-279-6542
Practice Address - Street 1:525 ROUTE 70 EAST
Practice Address - Street 2:SUITE 1-C
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-4022
Practice Address - Country:US
Practice Address - Phone:732-279-6537
Practice Address - Fax:732-279-6542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06682500302F00000X, 302R00000X, 305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service