1134292360 NPI number — FOREST HILL FAMILY HEALTH ASSOCIATES P A

Table of content: (NPI 1134292360)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134292360 NPI number — FOREST HILL FAMILY HEALTH ASSOCIATES P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOREST HILL FAMILY HEALTH ASSOCIATES P A
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:
1134292360
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/30/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
465 MT. PROSPECT AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-483-3640
Provider Business Mailing Address Fax Number:
973-483-0132

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
465 MT. PROSPECT AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEWARK
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-483-3640
Provider Business Practice Location Address Fax Number:
973-483-0132
Provider Enumeration Date:
11/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ORTIZ
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
R
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
973-485-6242

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1259202 . This is a "MEDICAID INDIVIDUAL PROVIDER" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3145107 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 033691BXB . This is a "MEDICARE GROUP SUFFIX" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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