Provider Demographics
NPI:1790821692
Name:HEATHPOINT MEDICAL GROUP OF KEYPORT, LLC
Entity Type:Organization
Organization Name:HEATHPOINT MEDICAL GROUP OF KEYPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:
Authorized Official - Last Name:LALLEMAND
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:732-613-1000
Mailing Address - Street 1:158 W 27TH ST
Mailing Address - Street 2:11TH FLOOR SOUTH
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-6216
Mailing Address - Country:US
Mailing Address - Phone:212-563-2497
Mailing Address - Fax:212-563-0605
Practice Address - Street 1:39 W FRONT ST
Practice Address - Street 2:
Practice Address - City:KEYPORT
Practice Address - State:NJ
Practice Address - Zip Code:07735-1209
Practice Address - Country:US
Practice Address - Phone:732-264-2224
Practice Address - Fax:732-264-4291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2009-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ117533Medicare PIN
NJ082526XAEMedicare PIN