Provider Demographics
NPI:1124154968
Name:P.G. MEDICAL ASSOCIATES PA
Entity type:Organization
Organization Name:P.G. MEDICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAO
Authorized Official - Middle Name:S
Authorized Official - Last Name:GOURKANTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-741-4668
Mailing Address - Street 1:31 SEVEN BRIDGES RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE SILVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07739-1634
Mailing Address - Country:US
Mailing Address - Phone:732-741-4668
Mailing Address - Fax:732-219-1681
Practice Address - Street 1:31 SEVEN BRIDGES RD
Practice Address - Street 2:
Practice Address - City:LITTLE SILVER
Practice Address - State:NJ
Practice Address - Zip Code:07739-1634
Practice Address - Country:US
Practice Address - Phone:732-741-4668
Practice Address - Fax:732-219-1681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA55303207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0074047Medicaid
NJ4620305Medicaid
NJ0074047Medicaid
NJ=========OtherTAX ID
NJ4620305Medicaid
NJE18872Medicare UPIN
NJG0628135Medicare ID - Type Unspecified