Provider Demographics
NPI:1871653790
Name:TICK BORNE DISEASE GROUP
Entity Type:Organization
Organization Name:TICK BORNE DISEASE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:LIONETTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-567-6044
Mailing Address - Street 1:PO BOX 271
Mailing Address - Street 2:
Mailing Address - City:HAMMONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08037
Mailing Address - Country:US
Mailing Address - Phone:609-567-6044
Mailing Address - Fax:609-567-6140
Practice Address - Street 1:210 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:PHILLIPSBURG
Practice Address - State:NJ
Practice Address - Zip Code:08865
Practice Address - Country:US
Practice Address - Phone:609-567-6044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA44448207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ046405Medicare ID - Type Unspecified