Basic Information
| Provider Information | |||||||||
| NPI: | 1144240482 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTIC GASTROENTEROLOGY ASSOCIATES, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3205 FIRE RD | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | EGG HARBOR TOWNSHIP | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082345857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6094071220 | ||||||||
| FaxNumber: | 6094070220 | ||||||||
| Practice Location | |||||||||
| Address1: | 3205 FIRE RD | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | EGG HARBOR TOWNSHIP | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082345857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6094071220 | ||||||||
| FaxNumber: | 6094070220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 08/26/2009 | ||||||||
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| AuthorizedOfficialLastName: | KAUFMAN | ||||||||
| AuthorizedOfficialFirstName: | BARRY | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6094071220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 222485119 | 01 | JOHN CHIESA INDIVIDUAL TI | OTHER | 25MB03629600 | 01 | NJ | JOHN J SANTORO STATE LICE | OTHER | 25MA01893500 | 01 | NJ | LEE P ROSKY STATE LICENSE | OTHER | 2959305 | 05 | NJ | MEDICAID | 25MA04967400 | 01 | NJ | GARY A ROSMAN STATE LICEN | OTHER | 25MB02888400 | 01 | NJ | JOHN CHIESA STATELICENSE | OTHER | 25MA05301400 | 01 | NJ | HOWARD N GARSON STATE LIC | OTHER | 25MA03429200 | 01 | NJ | BARRY P KAUFMAN STATE LIC | OTHER | 25MA03908500 | 01 | NJ | JOSEPH L SPAAR STATE LICE | OTHER | 25MA03637500 | 01 | NJ | NIKHILESH D MEHTA STATE L | OTHER |