Basic Information
Provider Information | |||||||||
NPI: | 1033494430 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UNIVERSITY HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 30 BERGEN STREET | ||||||||
Address2: | ADMC 1327 | ||||||||
City: | NEWARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 071011709 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9739720882 | ||||||||
FaxNumber: | 9739729129 | ||||||||
Practice Location | |||||||||
Address1: | 205 SOUTH ORANGE AVENUE | ||||||||
Address2: | DEPT. ONCOLOGY B-1245 | ||||||||
City: | NEWARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 071032785 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9739725053 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/17/2011 | ||||||||
LastUpdateDate: | 12/31/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HAMSTRA | ||||||||
AuthorizedOfficialFirstName: | NANCY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | INTERIM PRES./CEO | ||||||||
AuthorizedOfficialTelephone: | 9739724752 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.