Provider Demographics
NPI:1225214034
Name:BRANDON MACY
Entity type:Organization
Organization Name:BRANDON MACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:
Authorized Official - Last Name:MACY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:732-382-3470
Mailing Address - Street 1:1114 RARITAN RD
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1330
Mailing Address - Country:US
Mailing Address - Phone:732-382-3470
Mailing Address - Fax:
Practice Address - Street 1:1114 RARITAN RD
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1330
Practice Address - Country:US
Practice Address - Phone:732-382-3470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00126200332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3057101Medicaid
NJ461180Medicare PIN
NJ3057101Medicaid
NJ0866280001Medicare NSC