MEDICARE: NJ GASTRO, LLC

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	207RG0100X	Gastroenterology Physician		NJ
2	207RG0100X	Gastroenterology Physician

General Provider Information

NPI Number	:	1851525661
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NJ GASTRO, LLC

Provider Business Mailing Address
First Line	:	24 MERCHANT ST
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07105-2847
Country	:	US
Telephone Number	:	973-645-0000
Fax Number	:

Provider Business Practice Location Address
First Line	:	24 MERCHANT ST
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07105-2847
Country	:	US
Telephone Number	:	972-645-0000
Fax Number	:	973-645-0001

Authorized Official
Title or Position	:	OWNER
Name	:	DOMENICA MARIA BARRITTA
Credential	:	MD
Telephone Number	:	973-645-0000

Provider Enumeration Date	:	05/07/2009
Last Update Date	:	01/22/2020

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