Provider Demographics
NPI:1851825947
Name:GARDEN STATE SPECIALTY CARE, LLC
Entity Type:Organization
Organization Name:GARDEN STATE SPECIALTY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ATHANASIOS
Authorized Official - Middle Name:G
Authorized Official - Last Name:PAPASTAMELOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-469-1585
Mailing Address - Street 1:9822 TAPESTRY PARK CIR STE 208
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-9260
Mailing Address - Country:US
Mailing Address - Phone:609-469-1585
Mailing Address - Fax:
Practice Address - Street 1:2106 NEW RD STE F2
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1053
Practice Address - Country:US
Practice Address - Phone:609-469-1585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-14
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X, 208D00000X
NJ25MB05436700207RI0200X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0591661Medicaid