1841589298 NPI number — SOVEREIGN MEDICAL GROUP LLC

Table of content: (NPI 1841589298)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841589298 NPI number — SOVEREIGN MEDICAL GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOVEREIGN MEDICAL GROUP LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NEW JERSEY INSTITUTE OF RADIOLOGY PC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1841589298
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
630 BROAD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARLSTADT
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07072-1169
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-372-1020
Provider Business Mailing Address Fax Number:
201-372-1028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARLSTADT
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07072-1169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-372-1020
Provider Business Practice Location Address Fax Number:
201-372-1028
Provider Enumeration Date:
04/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HAJJAR
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
H
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
201-791-4544

Provider Taxonomy Codes

  • Taxonomy code: 207UN0901X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207UN0902X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085B0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085N0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085P0229X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085U0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0133311 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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