1992725832 NPI number — ERICKSON HEALTH MEDICAL GROUP OF NEW JERSEY PC

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 1992725832 NPI number — ERICKSON HEALTH MEDICAL GROUP OF NEW JERSEY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ERICKSON HEALTH MEDICAL GROUP 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:
1992725832
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5525 RESEARCH PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21228-4664
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-831-9540
Provider Business Mailing Address Fax Number:
973-831-3503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 CEDAR CREST VILLAGE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POMPTON PLAINS
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07444-2100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-831-3540
Provider Business Practice Location Address Fax Number:
973-831-3503
Provider Enumeration Date:
07/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NARRETT
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
410-402-2257

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 364SP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 52-2114204 . This is a "BCBS NJ" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0021873 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".