Provider Demographics
NPI:1457623886
Name:ANGELIC CARE CENTER LLC
Entity Type:Organization
Organization Name:ANGELIC CARE CENTER LLC
Other - Org Name:ANGELIC MEDICAL OF NORTH BRUNSWICK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:B
Authorized Official - Last Name:GALVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-246-8905
Mailing Address - Street 1:1102 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3622
Mailing Address - Country:US
Mailing Address - Phone:718-447-5072
Mailing Address - Fax:718-447-5178
Practice Address - Street 1:637 GEORGES RD
Practice Address - Street 2:
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-3331
Practice Address - Country:US
Practice Address - Phone:732-246-8905
Practice Address - Fax:718-447-5178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-01
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08523700207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01598654Medicaid
NYF27840Medicare UPIN
NY44F051Medicare PIN