Healthcare Provider Details

I. General information

NPI: 1245330588
Provider Name (Legal Business Name): RARITAN BAY MEDICAL CENTER PROFESSIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 NEW BRUNSWICK AVE
FORDS NJ
08863-2110
US

IV. Provider business mailing address

PO BOX 48270
NEWARK NJ
07101-4800
US

V. Phone/Fax

Practice location:
  • Phone: 732-738-4260
  • Fax: 732-738-5693
Mailing address:
  • Phone: 201-818-9118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA02674500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA04981500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA07930600
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA05842900
License Number StateNJ

VIII. Authorized Official

Name: TOM SHANAHAN
Title or Position: CEO
Credential:
Phone: 732-293-2314