Basic Information
| Provider Information | |||||||||
| NPI: | 1023224235 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HOSPITAL GROUP INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CENTER FOR BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 65 JAMES ST | ||||||||
| Address2: | |||||||||
| City: | EDISON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088203947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7326321571 | ||||||||
| FaxNumber: | 7326321644 | ||||||||
| Practice Location | |||||||||
| Address1: | 65 JAMES ST | ||||||||
| Address2: | |||||||||
| City: | EDISON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088203947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7326321571 | ||||||||
| FaxNumber: | 7326321644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 10/19/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SMITH | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7323217000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 200040104 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 0203050 | 05 | NJ | MEDICAID | 8087300 | 05 | NJ | MEDICAID |