Provider Demographics
NPI:1780970749
Name:MIDDLESEX MONMOUTH GASTROENTEROLOGY
Entity type:Organization
Organization Name:MIDDLESEX MONMOUTH GASTROENTEROLOGY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEBARD
Authorized Official - Suffix:
Authorized Official - Credentials:MPA
Authorized Official - Phone:732-577-1999
Mailing Address - Street 1:222 SCHANCK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-3068
Mailing Address - Country:US
Mailing Address - Phone:732-577-1999
Mailing Address - Fax:732-845-5356
Practice Address - Street 1:222 SCHANCK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-3068
Practice Address - Country:US
Practice Address - Phone:732-577-1999
Practice Address - Fax:732-845-5356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-28
Last Update Date:2011-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ071151OtherMEDICARE PTAN