Basic Information
| Provider Information | |||||||||
| NPI: | 1700112737 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GASTROENTEROLOGY HEALTHCARE P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 799 BLOOMFIELD AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | VERONA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070441301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734337600 | ||||||||
| FaxNumber: | 9734337462 | ||||||||
| Practice Location | |||||||||
| Address1: | 799 BLOOMFIELD AVE STE 102 | ||||||||
| Address2: | |||||||||
| City: | VERONA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070441301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734337600 | ||||||||
| FaxNumber: | 9734337462 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2009 | ||||||||
| LastUpdateDate: | 11/13/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MANZI | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9734337600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 25MA03690300 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 2095700 | 05 | NJ | MEDICAID |