Basic Information
| Provider Information | |||||||||
| NPI: | 1285618348 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCTIGUE | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 292 ATLANTIC ST | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076012103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014880066 | ||||||||
| FaxNumber: | 2014886769 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076011914 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014880066 | ||||||||
| FaxNumber: | 2014886769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 25MB05791500 | NJ | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 01950132 | 05 | NY | MEDICAID | 2205437000 | 01 | NJ | AMERIHEALTH- HMO | OTHER | 37613 | 01 | NJ | AMERIGROUP | OTHER | 1111812 | 01 | NJ | HORIZON NJ HEALTH- MERCY | OTHER | 1518020 | 01 | NJ | AMERIHEALTH- PPO | OTHER | 7550103 | 05 | NJ | MEDICAID |