Provider Demographics
NPI:1396800272
Name:QUAILBROOK FAMILY PHYSICIANS
Entity type:Organization
Organization Name:QUAILBROOK FAMILY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:BERTRAM
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-246-7440
Mailing Address - Street 1:27 CLYDE RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-5039
Mailing Address - Country:US
Mailing Address - Phone:732-246-7440
Mailing Address - Fax:732-249-5951
Practice Address - Street 1:27 CLYDE RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-5039
Practice Address - Country:US
Practice Address - Phone:732-246-7440
Practice Address - Fax:732-249-5951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2010-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26MA03435600207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ520662Medicare ID - Type Unspecified