Healthcare Provider Details

I. General information

NPI: 1699222406
Provider Name (Legal Business Name): GARDEN STATE MEDICAL TRANSPORTATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2016
Last Update Date: 09/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 STATE ST SUITE 203-B
HACKENSACK NJ
07601-5500
US

IV. Provider business mailing address

214 STATE ST SUITE 203-B
HACKENSACK NJ
07601-5500
US

V. Phone/Fax

Practice location:
  • Phone: 201-488-0170
  • Fax: 201-488-0172
Mailing address:
  • Phone: 201-488-0170
  • Fax: 201-488-0172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberGARD00220
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier6125701
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 2
Identifier1356469415
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerNATIONAL PROVIDER NUMBER
# 3
IdentifierGARD00220
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerNJ DEPARTMENT OF HEALTH

VIII. Authorized Official

Name: MR. RUSSELL A CULIN JR.
Title or Position: PRESIDENT
Credential:
Phone: 201-488-0170