Basic Information
| Provider Information | |||||||||
| NPI: | 1881665305 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ESSEX GASTROENTEROLOGY ASSOCIATES LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5 FRANKLIN AVE | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071093532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737597240 | ||||||||
| FaxNumber: | 9737597243 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 FRANKLIN AVE | ||||||||
| Address2: | SUITE 109 | ||||||||
| City: | BELLEVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071093532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737597240 | ||||||||
| FaxNumber: | 9737597243 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2006 | ||||||||
| LastUpdateDate: | 09/20/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GUERRERO | ||||||||
| AuthorizedOfficialFirstName: | BETSY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9737597240 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 0400087929 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 0070823 | 05 | NJ | MEDICAID |