MEDICARE: GASTROENTEROLOGY MEDICAL ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	25MA04429400	NJ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	CL6517	OTHER	NJ	RAILROAD MEDICARE GROUP #

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2400229	OTHER	NJ	GHI PPO GROUP #
2	0235258000	OTHER	NJ	AMERIHEALTH GROUP #
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	0182415	OTHER	NJ	AETNA HMO GROUP #
6	4476564	OTHER	NJ	AETNA PPO GROUP #

General Provider Information

NPI Number	:	1457393803
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GASTROENTEROLOGY MEDICAL ASSOCIATES

Provider Business Mailing Address
First Line	:	9223 KENNEDY BLVD
Second Line	:	SUITE D
City	:	NORTH BERGEN
State	:	NJ
Zip	:	07047-5322
Country	:	US
Telephone Number	:	201-868-2849
Fax Number	:	201-868-4190

Provider Business Practice Location Address
First Line	:	9223 KENNEDY BLVD
Second Line	:	SUITE D
City	:	NORTH BERGEN
State	:	NJ
Zip	:	07047-5322
Country	:	US
Telephone Number	:	201-868-2849
Fax Number	:	201-868-4190

Authorized Official
Title or Position	:	DELEGATED OFFICIAL
Name	:	ALAN PORT
Credential	:
Telephone Number	:	201-898-2849

Provider Enumeration Date	:	06/11/2006
Last Update Date	:	09/28/2007

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