Provider Demographics
NPI:1053757914
Name:PETER T HETZLER MD FACS LLC
Entity type:Organization
Organization Name:PETER T HETZLER MD FACS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:T
Authorized Official - Last Name:HETZLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-219-0447
Mailing Address - Street 1:200 WHITE RD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:LITTLE SILVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07739-1150
Mailing Address - Country:US
Mailing Address - Phone:732-219-0447
Mailing Address - Fax:
Practice Address - Street 1:200 WHITE RD
Practice Address - Street 2:SUITE 211
Practice Address - City:LITTLE SILVER
Practice Address - State:NJ
Practice Address - Zip Code:07739-1150
Practice Address - Country:US
Practice Address - Phone:732-219-0447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05342300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B36988Medicare UPIN