Healthcare Provider Details

I. General information

NPI: 1215124524
Provider Name (Legal Business Name): GARDEN STATE GASTROENTEROLOGY,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2007
Last Update Date: 10/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 PERRINE RD SUITE 231
OLD BRIDGE NJ
08857-2842
US

IV. Provider business mailing address

PO BOX 209
WICKATUNK NJ
07765-0209
US

V. Phone/Fax

Practice location:
  • Phone: 732-525-0600
  • Fax: 732-525-9777
Mailing address:
  • Phone: 732-525-0600
  • Fax: 732-525-9777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMA59602
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MRS. TRACEY DREVELUS HOM
Title or Position: OFFICE MANAGER
Credential:
Phone: 732-525-0600