1649341249 NPI number — GASTROENTEROLOGY MEDICAL ASSOCIATES

Table of content: (NPI 1649341249)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649341249 NPI number — GASTROENTEROLOGY MEDICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GASTROENTEROLOGY MEDICAL ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1649341249
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9223 KENNEDY BLVD
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
NORTH BERGEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07047-5359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-868-2849
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
142 PALISADE AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
JERSEY CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07306-1133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-792-7788
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PORT
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
Authorized Official Title or Position:
DELEGATED OFFICIAL
Authorized Official Telephone Number:
201-868-2849

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  25MA04429400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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