Basic Information
| Provider Information | |||||||||
| NPI: | 1497932271 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GASTROENTEROLOGY ASSOCIATES OF NEW JERSEY, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1130 MCBRIDE AVE | ||||||||
| Address2: | |||||||||
| City: | WOODLAND PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074243806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738121400 | ||||||||
| FaxNumber: | 9738121404 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 MCBRIDE AVE | ||||||||
| Address2: | |||||||||
| City: | WOODLAND PARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 074243806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9738121400 | ||||||||
| FaxNumber: | 9738121404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2008 | ||||||||
| LastUpdateDate: | 04/01/2022 | ||||||||
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| AuthorizedOfficialLastName: | ANDREANO | ||||||||
| AuthorizedOfficialFirstName: | RACHEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9737852277 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 207ZP0102X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 363AM0700X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RG0100X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 1945759 | 01 | NJ | AETNA HMO GROUP NUMBER | OTHER | 3533132000 | 01 | NJ | AMERIHEALTH GROUP NUMBER | OTHER | 0175714 | 05 | NJ | MEDICAID | 9341206 | 01 | NJ | AETNA PPO GROUP NUMBER | OTHER |