Provider Demographics
NPI:1942815295
Name:MYLAUREL MEDICAL GROUP NJ, PC
Entity Type:Organization
Organization Name:MYLAUREL MEDICAL GROUP NJ, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-417-6255
Mailing Address - Street 1:885 3RD AVE FL 29
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 MORRIS AVE STE 224
Practice Address - Street 2:
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-1362
Practice Address - Country:US
Practice Address - Phone:973-363-4555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-14
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty