Basic Information
| Provider Information | |||||||||
| NPI: | 1750459467 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HACKENSACK GASTROENTEROLOGY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 KINDERKAMACK RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | RIVER EDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076611939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014897772 | ||||||||
| FaxNumber: | 2014897411 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 KINDERKAMACK RD | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | RIVER EDGE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076611939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2014897772 | ||||||||
| FaxNumber: | 2014897411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2006 | ||||||||
| LastUpdateDate: | 10/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | LEIBOWITZ | ||||||||
| AuthorizedOfficialFirstName: | ARNOLD | ||||||||
| AuthorizedOfficialMiddleName: | JEROME | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2014897772 | ||||||||
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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 | 174400000X | 19460 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1316959976 | 01 | NJ | NPI NUMBER | OTHER | 1871505420 | 01 | NJ | NPI NUMBER | OTHER | 1679585236 | 01 | NJ | NPI NUMBER | OTHER | 1053323600 | 01 | NJ | NPI NUMBER | OTHER |