Provider Demographics
NPI:1750680393
Name:EAST BRUNSWICK PRIMARY CARE, PA
Entity Type:Organization
Organization Name:EAST BRUNSWICK PRIMARY CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:DENA
Authorized Official - Middle Name:Y
Authorized Official - Last Name:LI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-603-0055
Mailing Address - Street 1:15 TIMBER RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-3204
Mailing Address - Country:US
Mailing Address - Phone:732-603-0055
Mailing Address - Fax:732-603-8228
Practice Address - Street 1:F1 BRIER HILL CT
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-3337
Practice Address - Country:US
Practice Address - Phone:732-603-0055
Practice Address - Fax:732-603-8228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-22
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA69929261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ033103Medicare PIN
NJH07367Medicare UPIN