Basic Information
| Provider Information | |||||||||
| NPI: | 1710948302 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ENDOSCOPY CENTER OF RED BANK PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1A BURTON HILLS BLVD | ||||||||
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| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152403741 | ||||||||
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| Practice Location | |||||||||
| Address1: | 365 BROAD ST STE 2E | ||||||||
| Address2: | |||||||||
| City: | RED BANK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077012151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7328424294 | ||||||||
| FaxNumber: | 7325301497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 10/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | SNODGRASS | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6156651283 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 10/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0800X | N | Ambulatory Health Care Facilities | Clinic/Center | Endoscopy | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 31D0935445 | 01 | NJ | CLIA NUMBER | OTHER |