Basic Information
| Provider Information | |||||||||
| NPI: | 1356604409 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE DOCTORS OFFICE OF MANALAPAN LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 484 TEMPLE HILL RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | NEW WINDSOR | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125535557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455659400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 120 CRAIG RD | ||||||||
| Address2: | |||||||||
| City: | MANALAPAN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077263250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7324142991 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2012 | ||||||||
| LastUpdateDate: | 07/03/2014 | ||||||||
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| AuthorizedOfficialLastName: | RUVO | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8455653700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0410519 | 05 | NJ | MEDICAID |