Provider Demographics
NPI:1669462735
Name:BRIGANTINE MEDICAL GROUP PA
Entity Type:Organization
Organization Name:BRIGANTINE MEDICAL GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKLEER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-266-7557
Mailing Address - Street 1:353 12TH ST S
Mailing Address - Street 2:
Mailing Address - City:BRIGANTINE
Mailing Address - State:NJ
Mailing Address - Zip Code:08203-2211
Mailing Address - Country:US
Mailing Address - Phone:609-266-7557
Mailing Address - Fax:609-266-4450
Practice Address - Street 1:353 12TH ST S
Practice Address - Street 2:
Practice Address - City:BRIGANTINE
Practice Address - State:NJ
Practice Address - Zip Code:08203-2211
Practice Address - Country:US
Practice Address - Phone:609-266-7557
Practice Address - Fax:609-266-4450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2618907-1Medicaid
NJ2618907-1Medicaid