Healthcare Provider Details

I. General information

NPI: 1831384486
Provider Name (Legal Business Name): MANICKAM GANESH M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 PARK AVE
WEST ORANGE NJ
07052-5517
US

IV. Provider business mailing address

5 ECCLESTON CT
MONTVILLE NJ
07045-9663
US

V. Phone/Fax

Practice location:
  • Phone: 973-669-8181
  • Fax: 973-669-1687
Mailing address:
  • Phone: 973-669-8181
  • Fax: 973-669-1687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA03057000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number25MA03057000
License Number StateNJ

VIII. Authorized Official

Name: DR. MANICKAM GANESH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 973-669-8181