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General NPI Number Information
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NPI Number | 1457393803
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Entity Type | Organization
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Legal Business Name | GASTROENTEROLOGY MEDICAL ASSOCIATES
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Dates
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Enumeration Date | 06/11/2006
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Last Update Date | 09/28/2007
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Provider Practice Location Address
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Address Line | 9223 KENNEDY BLVD SUITE D
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City | NORTH BERGEN
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State | NJ
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Zip | 07047-5322
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Country | US
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Telephone | 201-868-2849
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Fax | 201-868-4190
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Provider Business Mailing Address
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Address Line | 9223 KENNEDY BLVD SUITE D
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City | NORTH BERGEN
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State | NJ
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Zip | 07047-5322
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Country | US
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Telephone | 201-868-2849
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Fax | 201-868-4190
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Authorized Official
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Title or Position | DELEGATED OFFICIAL
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Name | ALAN PORT
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Credential |
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Telephone | 201-898-2849
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 25MA04429400
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License Number State | NJ
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