1386772226 NPI number — THE CONNIE DWYER BREAST CENTER

Table of content: (NPI 1386772226)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386772226 NPI number — THE CONNIE DWYER BREAST CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE CONNIE DWYER BREAST 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:
1386772226
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2047
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH HACKENSACK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07606-0647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-968-9456
Provider Business Mailing Address Fax Number:
201-336-8198

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 CENTRAL AVE
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:
07102-1909
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-877-5189
Provider Business Practice Location Address Fax Number:
973-877-5205
Provider Enumeration Date:
03/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARPER
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING REPRESENTATIVE
Authorized Official Telephone Number:
201-996-4053

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  25MA02784400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 208600000X , with the licence number: 25MA07666200 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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