1376799932 NPI number — CAG MEMORIAL HEALTH CENTER

Table of content: (NPI 1376799932)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376799932 NPI number — CAG MEMORIAL HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAG MEMORIAL HEALTH CENTER
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:
1376799932
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 HARRISON AVE
Provider Second Line Business Mailing Address:
SUITE #2
Provider Business Mailing Address City Name:
JERSEY CITY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07304-2555
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-333-0094
Provider Business Mailing Address Fax Number:
201-333-6538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 HARRISON AVE
Provider Second Line Business Practice Location Address:
SUITE #2
Provider Business Practice Location Address City Name:
JERSEY CITY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07304-2555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
201-333-0094
Provider Business Practice Location Address Fax Number:
201-333-6538
Provider Enumeration Date:
08/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GIBBS
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
C.
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
201-333-0094

Provider Taxonomy Codes

  • Taxonomy code: 207QA0505X , with the licence number:  MAO13695 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01000097700 . This is a "AMERICHOICE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2684403 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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