Provider Demographics
NPI:1821031568
Name:BRIDGEWATER MEDICAL GROUP
Entity Type:Organization
Organization Name:BRIDGEWATER MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:LUSTIG
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:908-722-0808
Mailing Address - Street 1:766 US HIGHWAY 202/206
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-1777
Mailing Address - Country:US
Mailing Address - Phone:908-722-0808
Mailing Address - Fax:908-722-3415
Practice Address - Street 1:766 US HIGHWAY 202/206 NORTH
Practice Address - Street 2:SUITE 1
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-1773
Practice Address - Country:US
Practice Address - Phone:908-722-0808
Practice Address - Fax:908-722-3415
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-13
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2182OtherAETNA US HEALTHCARE GROUP
NJ2790203Medicaid
NJ2182OtherAETNA US HEALTHCARE GROUP