Provider Demographics
NPI:1720379878
Name:EDWARD A MERCOGLIANO MD PA
Entity Type:Organization
Organization Name:EDWARD A MERCOGLIANO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:MEROCGLIANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-284-0370
Mailing Address - Street 1:181 FRANKLIN AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-3820
Mailing Address - Country:US
Mailing Address - Phone:973-284-0370
Mailing Address - Fax:973-667-8547
Practice Address - Street 1:181 FRANKLIN AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-3820
Practice Address - Country:US
Practice Address - Phone:973-284-0370
Practice Address - Fax:973-667-8547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02603700208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2839300Medicaid