Basic Information
Provider Information | |||||||||
NPI: | 1225323967 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OLD BRIDGE ANESTHESIOLOGY PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BAY PAIN MANAGEMENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 135 | ||||||||
Address2: |   | ||||||||
City: | ORADELL | ||||||||
State: | NJ | ||||||||
PostalCode: | 076490135 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2013421205 | ||||||||
FaxNumber: | 2013421259 | ||||||||
Practice Location | |||||||||
Address1: | 530 NEW BRUNSWICK AVE | ||||||||
Address2: |   | ||||||||
City: | PERTH AMBOY | ||||||||
State: | NJ | ||||||||
PostalCode: | 088613654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2013421205 | ||||||||
FaxNumber: | 2013421259 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2011 | ||||||||
LastUpdateDate: | 11/29/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CITRON | ||||||||
AuthorizedOfficialFirstName: | ANDREW | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | V. PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2013421205 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | OLD BRIDGE ANESTHESIOLOGY | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.