Healthcare Provider Details

I. General information

NPI: 1205007622
Provider Name (Legal Business Name): PENINSULA EMERGENCY ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 E 29TH ST
BAYONNE NJ
07002-4654
US

IV. Provider business mailing address

66 WEST GILBERT ST
RED BANK NJ
07701
US

V. Phone/Fax

Practice location:
  • Phone: 201-858-5000
  • Fax:
Mailing address:
  • Phone: 732-212-0051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANE CLARKE
Title or Position: PRESIDENT
Credential: MD
Phone: 732-212-0051