Healthcare Provider Details

I. General information

NPI: 1306939434
Provider Name (Legal Business Name): RARITAN BAY MEDICAL CENTER PROFESSIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 LAWRIE ST
PERTH AMBOY NJ
08861-3046
US

IV. Provider business mailing address

PO BOX 48277
NEWARK NJ
07101-4800
US

V. Phone/Fax

Practice location:
  • Phone: 732-324-5231
  • Fax: 732-324-5233
Mailing address:
  • Phone: 201-818-9118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA07854400
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA07867800
License Number StateNJ

VIII. Authorized Official

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