Provider Demographics
NPI:1912916693
Name:OLD TAPPAN MEDICAL GROUP, PA
Entity Type:Organization
Organization Name:OLD TAPPAN MEDICAL GROUP, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:VARHOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-666-1000
Mailing Address - Street 1:215 OLD TAPPAN RD
Mailing Address - Street 2:
Mailing Address - City:OLD TAPPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-7000
Mailing Address - Country:US
Mailing Address - Phone:201-666-1000
Mailing Address - Fax:201-666-7610
Practice Address - Street 1:215 OLD TAPPAN RD
Practice Address - Street 2:
Practice Address - City:OLD TAPPAN
Practice Address - State:NJ
Practice Address - Zip Code:07675-7000
Practice Address - Country:US
Practice Address - Phone:201-666-1000
Practice Address - Fax:201-666-7610
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3695OtherAETNA CAPITATION NUMBER
NJ2672901Medicaid
087710OtherAETNA CAPITATION NUMBER
526213Medicare PIN