Provider Demographics
NPI:1104227990
Name:ST. MICHAELS MEDICAL CENTER
Entity type:Organization
Organization Name:ST. MICHAELS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERNAL MEDICINE PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:SHAYNE
Authorized Official - Last Name:DAZLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-259-8446
Mailing Address - Street 1:927 RIDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:MILLBURN
Mailing Address - State:NJ
Mailing Address - Zip Code:07041-1441
Mailing Address - Country:US
Mailing Address - Phone:732-259-8446
Mailing Address - Fax:
Practice Address - Street 1:927 RIDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:MILLBURN
Practice Address - State:NJ
Practice Address - Zip Code:07041-1441
Practice Address - Country:US
Practice Address - Phone:732-259-8446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MICHAELS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09562500281P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes281P00000XHospitalsChronic Disease Hospital