Provider Demographics
NPI:1942277223
Name:KENNETH FAISTL, MD,PA
Entity Type:Organization
Organization Name:KENNETH FAISTL, MD,PA
Other - Org Name:FAMILY PRACTICE OF CENTRAL JERSEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:FAISTL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-462-9622
Mailing Address - Street 1:17 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-1703
Mailing Address - Country:US
Mailing Address - Phone:732-462-9622
Mailing Address - Fax:732-780-0014
Practice Address - Street 1:17 BROAD ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-1703
Practice Address - Country:US
Practice Address - Phone:732-462-9622
Practice Address - Fax:732-780-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-04
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7461402Medicaid
NJ005191Medicare ID - Type UnspecifiedMEDICARE GROUP