Basic Information
| Provider Information | |||||||||
| NPI: | 1942424783 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHANGEBRIDGE MEDICAL ASSOCIATES PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 170 CHANGEBRIDGE RD | ||||||||
| Address2: | SUITE C-3 | ||||||||
| City: | MONTVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070459112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735755540 | ||||||||
| FaxNumber: | 9755754885 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 CHANGEBRIDGE RD. | ||||||||
| Address2: | SUITE C-3 | ||||||||
| City: | MONTVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070459112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735755540 | ||||||||
| FaxNumber: | 9735754885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2007 | ||||||||
| LastUpdateDate: | 09/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | PALLAY | ||||||||
| AuthorizedOfficialFirstName: | ARNOLD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9735755540 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5655102 | 05 | NJ | MEDICAID |