Provider Demographics
NPI:1902092281
Name:EATONTOWN PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:EATONTOWN PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:MANAR
Authorized Official - Middle Name:H
Authorized Official - Last Name:HANNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-542-4411
Mailing Address - Street 1:117 STATE ROUTE 35
Mailing Address - Street 2:
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724-1885
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 STATE ROUTE 35
Practice Address - Street 2:
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724-1885
Practice Address - Country:US
Practice Address - Phone:732-542-4411
Practice Address - Fax:732-542-1070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07738500174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ099326OtherMEDICARE GROUP NUMBER
NJ099326OtherMEDICARE GROUP NUMBER