Provider Demographics
NPI:1932507183
Name:ATLANTIC AGE MANAGEMENT
Entity Type:Organization
Organization Name:ATLANTIC AGE MANAGEMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-489-4648
Mailing Address - Street 1:34 MANCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-1366
Mailing Address - Country:US
Mailing Address - Phone:609-489-4648
Mailing Address - Fax:
Practice Address - Street 1:34 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-1366
Practice Address - Country:US
Practice Address - Phone:609-489-4648
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA 51879207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E23759Medicare UPIN