Basic Information
| Provider Information | |||||||||
| NPI: | 1841373313 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RUTGERS HEALTH-RWJ SCLERODERMA PROGRAM | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | RUTGERS HEALTH-RWJ PEDIATRIC G.I. | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 W GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | RED BANK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322120051 | ||||||||
| FaxNumber: | 7322120713 | ||||||||
| Practice Location | |||||||||
| Address1: | 89 FRENCH STREET | ||||||||
| Address2: | SUITE 2300 | ||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322356230 | ||||||||
| FaxNumber: | 7322358766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 01/19/2021 | ||||||||
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| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | BRENDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 7322356070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0206X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 5111005 | 05 | NJ | MEDICAID |