Provider Demographics
NPI:1265529523
Name:RARITAN BAY MEDICAL CENTER PROFESSIONAL SERVICES
Entity type:Organization
Organization Name:RARITAN BAY MEDICAL CENTER PROFESSIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-293-2314
Mailing Address - Street 1:PO BOX 48270
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07101-4800
Mailing Address - Country:US
Mailing Address - Phone:201-818-9118
Mailing Address - Fax:
Practice Address - Street 1:530 NEW BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3654
Practice Address - Country:US
Practice Address - Phone:732-324-6065
Practice Address - Fax:732-324-6063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04033300174400000X
NJ25MA07854400174400000X
NJ25MA07056200174400000X
NJ25MA07043800174400000X
NJ25MA07115800174400000X
NJ25MA05898100174400000X
NJ25MA02777800174400000X
NJ25MA05255000174400000X
NJ25MA05746900174400000X
NJ25MA05696500174400000X
NJ25MA05873200174400000X
NJ25MA03053200174400000X
NJ25MA02710200174400000X
NJ25MA03479600174400000X
NJ25MA07766200174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTAX IDENTIFICATION NUMBER