MEDICARE: RARITAN BAY MEDICAL CENTER PROFESSIONAL SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	25MA02674500	NJ
2	174400000X	Specialist	25MA04981500	NJ
3	174400000X	Specialist	25MA07930600	NJ
4	174400000X	Specialist	25MA05842900	NJ

General Provider Information

NPI Number	:	1245330588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RARITAN BAY MEDICAL CENTER PROFESSIONAL SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 48270
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07101-4800
Country	:	US
Telephone Number	:	201-818-9118
Fax Number	:

Provider Business Practice Location Address
First Line	:	390 NEW BRUNSWICK AVE
Second Line	:
City	:	FORDS
State	:	NJ
Zip	:	08863-2110
Country	:	US
Telephone Number	:	732-738-4260
Fax Number	:	732-738-5693

Authorized Official
Title or Position	:	CEO
Name	:	TOM SHANAHAN
Credential	:
Telephone Number	:	732-293-2314

Provider Enumeration Date	:	09/25/2006
Last Update Date	:	08/22/2020

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