Healthcare Provider Details

I. General information

NPI: 1073944005
Provider Name (Legal Business Name): THE GASTROENTEROLOGY GROUP OF NORTHERN NEW JERSEY,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 GRAND AVE SUITE 101
ENGLEWOOD NJ
07631-4152
US

IV. Provider business mailing address

420 GRAND AVE SUITE 101
ENGLEWOOD NJ
07631
US

V. Phone/Fax

Practice location:
  • Phone: 201-569-7044
  • Fax: 201-569-1999
Mailing address:
  • Phone: 201-569-7044
  • Fax: 201-569-1999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number25MA03997000
License Number StateNJ

VIII. Authorized Official

Name: DR. IVAN A FRIEDRICH
Title or Position: PHYSICIAN/BOARD OF GOVERNORS
Credential: M.D.
Phone: 201-569-7044