1467636936 NPI number — CATHEDRAL FACULTY PRACTICE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467636936 NPI number — CATHEDRAL FACULTY PRACTICE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CATHEDRAL FACULTY PRACTICE
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:
1467636936
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66 W GILBERT ST
Provider Second Line Business Mailing Address:
2ND FLOOR
Provider Business Mailing Address City Name:
RED BANK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07701-4819
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-212-0051
Provider Business Mailing Address Fax Number:
732-212-0052

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
268 DR. MARTIN LUTHER KING BOULEVARD
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:
07102-2094
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-877-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDFARB
Authorized Official First Name:
IRVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PHYSICIAN
Authorized Official Telephone Number:
973-877-5000

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , 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: G870739 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: CN9725 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7007507 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1065131 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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