Provider Demographics
NPI:1174899926
Name:INTERGRATIVE OBGYN LLC
Entity type:Organization
Organization Name:INTERGRATIVE OBGYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:DE ANGELIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-561-1102
Mailing Address - Street 1:775 MOUNTAIN BLVD STE 107
Mailing Address - Street 2:
Mailing Address - City:WATCHUNG
Mailing Address - State:NJ
Mailing Address - Zip Code:07069-6262
Mailing Address - Country:US
Mailing Address - Phone:908-561-1102
Mailing Address - Fax:908-561-1105
Practice Address - Street 1:110 REHILL AVE
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2519
Practice Address - Country:US
Practice Address - Phone:908-685-2200
Practice Address - Fax:908-561-1105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ0600382326207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ035762YE2Medicare UPIN
NJ127318YEZMedicare UPIN