Provider Demographics
NPI:1740315225
Name:EAST 29TH ST MEDICAL ASSOCIATES, P.C.
Entity type:Organization
Organization Name:EAST 29TH ST MEDICAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SAMUEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-281-8692
Mailing Address - Street 1:716 HUNTINGTON CHASE CT
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-2681
Mailing Address - Country:US
Mailing Address - Phone:201-281-8692
Mailing Address - Fax:
Practice Address - Street 1:542 E 29TH STREET
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07504-1814
Practice Address - Country:US
Practice Address - Phone:201-281-8691
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA71838207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8598703Medicaid
NJ8598703Medicaid
NJ050702Medicare PIN
NJG59503Medicare UPIN