Basic Information
Provider Information | |||||||||
NPI: | 1003805763 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | IBAY | ||||||||
FirstName: | ANNAMARIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7000 ATRIUM WAY | ||||||||
Address2: | SUITE 6 | ||||||||
City: | MOUNT LAUREL | ||||||||
State: | NJ | ||||||||
PostalCode: | 080543917 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8562916818 | ||||||||
FaxNumber: | 8562916819 | ||||||||
Practice Location | |||||||||
Address1: | 1636 ROUTE 38 AND EAYRESTOWN ROAD | ||||||||
Address2: |   | ||||||||
City: | LUMBERTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 080480000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6099148440 | ||||||||
FaxNumber: | 6099148441 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2005 | ||||||||
LastUpdateDate: | 10/19/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/19/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MA07609100 | NJ | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 0042871 | 05 | NJ |   | MEDICAID |