Healthcare Provider Details

I. General information

NPI: 1104008374
Provider Name (Legal Business Name): GARDEN STATE BARIATRICS & WELLNESS CENTER,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 02/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 MILLBURN AVE SUITE 204
MILLBURN NJ
07041-1737
US

IV. Provider business mailing address

225 MILLBURN AVE SUITE 204
MILLBURN NJ
07041-1737
US

V. Phone/Fax

Practice location:
  • Phone: 973-218-1990
  • Fax: 973-629-1274
Mailing address:
  • Phone: 973-218-1990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QB0002X
TaxonomyObesity Medicine (Family Medicine) Physician
License NumberNJ25MA05641900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License NumberNJ25MA05641900
License Number StateNJ

VIII. Authorized Official

Name: DR. MICHAEL L BILOF
Title or Position: OWNER
Credential: M.D.
Phone: 973-218-1990