=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780970749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDDLESEX MONMOUTH GASTROENTEROLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2011
-----------------------------------------------------
Last Update Date | 06/28/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 222 SCHANCK RD SUITE 100
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728-3068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-577-1999
-----------------------------------------------------
Fax | 732-845-5356
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 SCHANCK RD SUITE 100
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728-3068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-577-1999
-----------------------------------------------------
Fax | 732-845-5356
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | SUSAN DEBARD
-----------------------------------------------------
Credential | MPA
-----------------------------------------------------
Telephone | 732-577-1999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------