Provider Demographics
NPI:1962404350
Name:GARDEN STATE ORTHOPAEDIC, INC.
Entity type:Organization
Organization Name:GARDEN STATE ORTHOPAEDIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:HABERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:CPO
Authorized Official - Phone:973-538-4948
Mailing Address - Street 1:95 MOUNT KEMBLE AVE
Mailing Address - Street 2:ANNEX BUILDING
Mailing Address - City:MORRISTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07960-5155
Mailing Address - Country:US
Mailing Address - Phone:973-538-4948
Mailing Address - Fax:973-605-8481
Practice Address - Street 1:95 MOUNT KEMBLE AVE
Practice Address - Street 2:ANNEX BUILDING
Practice Address - City:MORRISTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07960-5155
Practice Address - Country:US
Practice Address - Phone:973-538-4948
Practice Address - Fax:973-605-8481
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ#36877OtherAETNA PROVIDER NUMBER
NJ3897206-01Medicaid
NJ=========OtherHORIZON BCBS PROVIDER NO.