Basic Information
| Provider Information | |||||||||
| NPI: | 1164489621 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEACREST MEDICAL ASSOCIATES, P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 66 W GILBERT ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | TINTON FALLS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077014918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322120060 | ||||||||
| FaxNumber: | 7322120061 | ||||||||
| Practice Location | |||||||||
| Address1: | 1160 RAYMOND BLVD | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071024168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735963857 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CALABRO | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7322120060 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 2084N0400X | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207R00000X | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 2084P0800X | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | DA3466 & CK8172 | 01 | NJ | RAILROAD MEDICARE | OTHER | 0004561 | 05 | NJ | MEDICAID | 2392545000 | 01 | NJ | AMERIHEALTH | OTHER | 6113092 | 01 | NJ | BLACK LUNG | OTHER |