Provider Demographics
NPI:1811942766
Name:ST MICHAEL INFECTIOUS DISEASE ASSOCIATES
Entity type:Organization
Organization Name:ST MICHAEL INFECTIOUS DISEASE ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-877-2586
Mailing Address - Street 1:PO BOX 36
Mailing Address - Street 2:
Mailing Address - City:ROSELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07068-0036
Mailing Address - Country:US
Mailing Address - Phone:201-512-9494
Mailing Address - Fax:
Practice Address - Street 1:265 DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-2012
Practice Address - Country:US
Practice Address - Phone:973-877-2586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA060236207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8420301Medicaid
NJG30983Medicare UPIN
NJ046281Medicare ID - Type Unspecified