Provider Demographics
NPI:1831384486
Name:MANICKAM GANESH M.D., P.A.
Entity type:Organization
Organization Name:MANICKAM GANESH M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MANICKAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GANESH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-669-8181
Mailing Address - Street 1:5 ECCLESTON CT
Mailing Address - Street 2:
Mailing Address - City:MONTVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07045-9663
Mailing Address - Country:US
Mailing Address - Phone:973-669-8181
Mailing Address - Fax:973-669-1687
Practice Address - Street 1:24 PARK AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-5517
Practice Address - Country:US
Practice Address - Phone:973-669-8181
Practice Address - Fax:973-669-1687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03057000207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2957604Medicaid
NJ2957604Medicaid
NJ028676Medicare PIN