Healthcare Provider Details

I. General information

NPI: 1538147582
Provider Name (Legal Business Name): GASTROENTEROLGY CENTER, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2006
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 PLYMOUTH ST
MONTCLAIR NJ
07042-2607
US

IV. Provider business mailing address

21 PLYMOUTH ST
MONTCLAIR NJ
07042-2607
US

V. Phone/Fax

Practice location:
  • Phone: 973-746-5166
  • Fax: 973-746-7922
Mailing address:
  • Phone: 973-746-5166
  • Fax: 973-746-7922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMA-16509
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number25MA08496100
License Number StateNJ

VIII. Authorized Official

Name: DR. VICTOR GROISSER
Title or Position: OWNER
Credential: MD
Phone: 973-746-5166