Provider Demographics
NPI:1750660122
Name:NORTH ATLANTIC DIAGNOSTIC
Entity Type:Organization
Organization Name:NORTH ATLANTIC DIAGNOSTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:GIBBENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-539-8714
Mailing Address - Street 1:4 SYCAMORE LN
Mailing Address - Street 2:
Mailing Address - City:RUMSON
Mailing Address - State:NJ
Mailing Address - Zip Code:07760-1035
Mailing Address - Country:US
Mailing Address - Phone:732-539-8714
Mailing Address - Fax:732-933-0379
Practice Address - Street 1:4 SYCAMORE LN
Practice Address - Street 2:
Practice Address - City:RUMSON
Practice Address - State:NJ
Practice Address - Zip Code:07760-1035
Practice Address - Country:US
Practice Address - Phone:732-539-8714
Practice Address - Fax:732-933-0379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA06225500204R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204R00000XAllopathic & Osteopathic PhysiciansElectrodiagnostic MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6581803Medicaid
NJ6581803Medicaid
NJG1742184Medicare PIN