Provider Demographics
NPI:1902804693
Name:ATLANTIC GYNECOLOGIC ON
Entity Type:Organization
Organization Name:ATLANTIC GYNECOLOGIC ON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MENDUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-280-5464
Mailing Address - Street 1:3349 HWY 138
Mailing Address - Street 2:BLDG B SUITE F
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-9671
Mailing Address - Country:US
Mailing Address - Phone:732-280-5464
Mailing Address - Fax:732-280-5443
Practice Address - Street 1:3349 HWY 138
Practice Address - Street 2:BLDG B SUITE F
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-9671
Practice Address - Country:US
Practice Address - Phone:732-280-5464
Practice Address - Fax:732-280-5443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-07
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB48253207VX0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0201XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologic OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6734502Medicaid
NJCG6895OtherRAIL ROAD MEDICARE
NJCG6895OtherRAIL ROAD MEDICARE
NJ6734502Medicaid