Provider Demographics
NPI:1457393803
Name:GASTROENTEROLOGY MEDICAL ASSOCIATES
Entity Type:Organization
Organization Name:GASTROENTEROLOGY MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PORT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-898-2849
Mailing Address - Street 1:9223 KENNEDY BLVD
Mailing Address - Street 2:SUITE D
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-5322
Mailing Address - Country:US
Mailing Address - Phone:201-868-2849
Mailing Address - Fax:201-868-4190
Practice Address - Street 1:9223 KENNEDY BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-5322
Practice Address - Country:US
Practice Address - Phone:201-868-2849
Practice Address - Fax:201-868-4190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04429400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2400229OtherGHI PPO GROUP #
NJ0235258000OtherAMERIHEALTH GROUP #
NJCL6517OtherRAILROAD MEDICARE GROUP #
NJ5529701Medicaid
NJ0182415OtherAETNA HMO GROUP #
NJ4476564OtherAETNA PPO GROUP #
NJCL6517OtherRAILROAD MEDICARE GROUP #