Provider Demographics
NPI:1316093719
Name:GARDEN STATE CARDIOLOGY
Entity type:Organization
Organization Name:GARDEN STATE CARDIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DWYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-689-0091
Mailing Address - Street 1:1 W RIDGEWOOD AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-2359
Mailing Address - Country:US
Mailing Address - Phone:201-689-0091
Mailing Address - Fax:201-689-9404
Practice Address - Street 1:1124 E RIDGEWOOD AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3915
Practice Address - Country:US
Practice Address - Phone:201-689-0091
Practice Address - Fax:201-689-9404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA04851100174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0529206Medicaid
NJ040915DV9Medicare ID - Type UnspecifiedSIMON MDCR
NJC56519Medicare UPIN
NJF80563Medicare UPIN
NJ503311DV9Medicare ID - Type UnspecifiedKESS MDCR
NJ0529206Medicaid
NJ068833DV9Medicare ID - Type UnspecifiedSAP MDCR