Provider Demographics
NPI:1881644011
Name:WOODBRIDGE MEDICAL GROUP, P.A
Entity Type:Organization
Organization Name:WOODBRIDGE MEDICAL GROUP, P.A
Other - Org Name:MAIN STREET PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOYD
Authorized Official - Suffix:
Authorized Official - Credentials:D O
Authorized Official - Phone:732-636-5252
Mailing Address - Street 1:270 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07095-1927
Mailing Address - Country:US
Mailing Address - Phone:732-636-5252
Mailing Address - Fax:732-636-5452
Practice Address - Street 1:270 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07095-1927
Practice Address - Country:US
Practice Address - Phone:732-636-5252
Practice Address - Fax:732-636-5452
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB30335207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ517215Medicare PIN
NJC54818Medicare UPIN