Basic Information
| Provider Information | |||||||||
| NPI: | 1215960133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BALDOMERO | ||||||||
| FirstName: | ANITA | ||||||||
| MiddleName: | C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 WEST GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | REDBANK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322120051 | ||||||||
| FaxNumber: | 7322120713 | ||||||||
| Practice Location | |||||||||
| Address1: | 94 OLD SHORT HILLS RD | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070395672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733225437 | ||||||||
| FaxNumber: | 9733228833 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MA03706900 | NJ | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2067005 | 05 | NJ | MEDICAID |