Provider Demographics
NPI:1952342750
Name:MID ATLANTIC GERIATRIC ASSOCIATION
Entity Type:Organization
Organization Name:MID ATLANTIC GERIATRIC ASSOCIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:R
Authorized Official - Last Name:SHUA-HAIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACP AGSF CMD
Authorized Official - Phone:732-663-0099
Mailing Address - Street 1:1205 ROUTE 35
Mailing Address - Street 2:
Mailing Address - City:OCEAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07712-4051
Mailing Address - Country:US
Mailing Address - Phone:732-663-0099
Mailing Address - Fax:732-663-1359
Practice Address - Street 1:1205 ROUTE 35
Practice Address - Street 2:
Practice Address - City:OCEAN
Practice Address - State:NJ
Practice Address - Zip Code:07712-4051
Practice Address - Country:US
Practice Address - Phone:732-663-0099
Practice Address - Fax:732-663-1359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05837900207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ057355Medicare ID - Type Unspecified