=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821031568
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRIDGEWATER MEDICAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2006
-----------------------------------------------------
Last Update Date | 06/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 766 US HIGHWAY 202/206 NORTH SUITE 1
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08807-1773
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-722-0808
-----------------------------------------------------
Fax | 908-722-3415
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 766 US HIGHWAY 202/206 SUITE 1
-----------------------------------------------------
City | BRIDGEWATER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08807-1777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-722-0808
-----------------------------------------------------
Fax | 908-722-3415
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT H LUSTIG
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 908-722-0808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------