Healthcare Provider Details

I. General information

NPI: 1669462735
Provider Name (Legal Business Name): BRIGANTINE MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

353 12TH ST S
BRIGANTINE NJ
08203-2211
US

IV. Provider business mailing address

353 12TH ST S
BRIGANTINE NJ
08203-2211
US

V. Phone/Fax

Practice location:
  • Phone: 609-266-7557
  • Fax: 609-266-4450
Mailing address:
  • Phone: 609-266-7557
  • Fax: 609-266-4450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number StateNJ

VIII. Authorized Official

Name: MRS. BARBARA MACKLEER
Title or Position: OFFICE MANAGER
Credential:
Phone: 609-266-7557