Basic Information
| Provider Information | |||||||||
| NPI: | 1184067944 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DOCTORS OFFICE OF BRICK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 484 TEMPLE HILL RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | NEW WINDSOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125535557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455653700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 686 ROUTE 70 | ||||||||
| Address2: | |||||||||
| City: | BRICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087234026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322628200 | ||||||||
| FaxNumber: | 7322628203 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2013 | ||||||||
| LastUpdateDate: | 07/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | RUVO | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | GEN PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8455653700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 0410411 | 05 | NJ | MEDICAID |