Provider Demographics
NPI:1578650628
Name:HACKETTSTOWN MEDICAL P.C.
Entity type:Organization
Organization Name:HACKETTSTOWN MEDICAL P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KERI
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:INGRASSIA-SQUIERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:908-979-0050
Mailing Address - Street 1:5 HASTINGS SQUARE MALL
Mailing Address - Street 2:SCHOOLEYS MOUNTAIN ROAD
Mailing Address - City:HACKETTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07840-4227
Mailing Address - Country:US
Mailing Address - Phone:908-979-0050
Mailing Address - Fax:
Practice Address - Street 1:5 HASTINGS SQUARE MALL
Practice Address - Street 2:SCHOOLEYS MOUNTAIN ROAD
Practice Address - City:HACKETTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07840-4227
Practice Address - Country:US
Practice Address - Phone:908-979-0050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMARY CARE PARTNERS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-09
Last Update Date:2014-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB72580207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH93512Medicare UPIN
NJ090967Medicare ID - Type Unspecified