Provider Demographics
NPI:1801178736
Name:OM MEDICAL GROUP PC
Entity Type:Organization
Organization Name:OM MEDICAL GROUP PC
Other - Org Name:BRANFORD MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:COLLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-424-0080
Mailing Address - Street 1:23 BRANFORD PL
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-2711
Mailing Address - Country:US
Mailing Address - Phone:973-424-0080
Mailing Address - Fax:973-424-0088
Practice Address - Street 1:23 BRANFORD PL
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-2711
Practice Address - Country:US
Practice Address - Phone:973-424-0080
Practice Address - Fax:973-424-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-16
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04353300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty