1124122387 NPI number — CLINICAL HEALTH CARE ASSOCIATES OF NEW JERSEY PC

Table of content: (NPI 1124122387)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124122387 NPI number — CLINICAL HEALTH CARE ASSOCIATES OF NEW JERSEY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINICAL HEALTH CARE ASSOCIATES OF NEW JERSEY PC
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:
Provider Other Organization Name Type Code:
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:
1124122387
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3624 MARKET ST
Provider Second Line Business Mailing Address:
SUITE 560W
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19104-2614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-662-2286
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1400 ROUTE 70 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHERRY HILL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08034-2230
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-216-0300
Provider Business Practice Location Address Fax Number:
856-216-7148
Provider Enumeration Date:
09/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
CHANTE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
ENROLLMENT LEAD
Authorized Official Telephone Number:
215-662-6187

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0001X , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 2Y21758 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 554338 . This is a "NJ BLUE SHIELD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 867643 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0482067000 . This is a "NJ AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: DD7381 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3201503 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".