Basic Information
| Provider Information | |||||||||
| NPI: | 1093760266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LOUIE | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 766 SHREWSBURY AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | TINTON FALLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077243001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323458346 | ||||||||
| FaxNumber: | 7323458351 | ||||||||
| Practice Location | |||||||||
| Address1: | 1153 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100657768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6463862250 | ||||||||
| FaxNumber: | 8479194615 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 10/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 25MA06188200 | NJ | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0204X | 25MA06188200 | NJ | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | 2085R0204X | 178854-1 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 400113300 | 05 | NJ | MEDICAID |