Basic Information
| Provider Information | |||||||||
| NPI: | 1336343185 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MONTCLAIR GASTROENTEROLOGY CONSULTANTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 590 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN LAKES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074170590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737489166 | ||||||||
| FaxNumber: | 9737481373 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HIGHLAND AVE | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | GLEN RIDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070281528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737489166 | ||||||||
| FaxNumber: | 9737481373 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | OH | ||||||||
| AuthorizedOfficialFirstName: | SANGBAEK | ||||||||
| AuthorizedOfficialMiddleName: | CHARLES | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9737489166 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | MA068787 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.