Provider Demographics
NPI:1396746962
Name:PRINCETON GASTROENTEROLOGY ASSOC
Entity type:Organization
Organization Name:PRINCETON GASTROENTEROLOGY ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:OSIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-924-1422
Mailing Address - Street 1:731 ALEXANDER RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-6345
Mailing Address - Country:US
Mailing Address - Phone:609-924-1422
Mailing Address - Fax:609-924-7473
Practice Address - Street 1:731 ALEXANDER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:PRINCETON
Practice Address - State:NJ
Practice Address - Zip Code:08540-6345
Practice Address - Country:US
Practice Address - Phone:609-924-1422
Practice Address - Fax:609-924-7473
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
57811OtherAETNA
0821011000OtherAMERIHEALTH
CE7422OtherMEDICAID FOR RR
NJ603595Medicare PIN
57811OtherAETNA