Basic Information
| Provider Information | |||||||||
| NPI: | 1396762050 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAINLAND HEART CONSULTANTS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 318 CHRIS GAUPP DR | ||||||||
| Address2: | |||||||||
| City: | GALLOWAY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082054460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6094049900 | ||||||||
| FaxNumber: | 6094043653 | ||||||||
| Practice Location | |||||||||
| Address1: | 318 CHRIS GAUPP DR | ||||||||
| Address2: | |||||||||
| City: | GALLOWAY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082054460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6094049900 | ||||||||
| FaxNumber: | 6094043653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 10/19/2010 | ||||||||
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| AuthorizedOfficialLastName: | GANSERT | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINSTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 6094049900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 605324 | 01 | NJ | AETNA | OTHER | G537870 | 01 | NJ | OXFORD | OTHER | 0364554000 | 01 | NJ | AMERIHEALTH | OTHER |