Provider Demographics
NPI:1366827313
Name:MARY DAISY CANTEY MD CAROLINA MEDICAL ASSOCIATES LLC
Entity type:Organization
Organization Name:MARY DAISY CANTEY MD CAROLINA MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:DAISY
Authorized Official - Last Name:CANTEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-532-7898
Mailing Address - Street 1:312 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2502
Mailing Address - Country:US
Mailing Address - Phone:973-532-7898
Mailing Address - Fax:973-821-5999
Practice Address - Street 1:312 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-2502
Practice Address - Country:US
Practice Address - Phone:973-532-7898
Practice Address - Fax:973-821-5999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-20
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07425300208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8941106Medicaid
NJ8941106Medicaid