Basic Information
| Provider Information | |||||||||
| NPI: | 1063683258 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEWARK COMMUNITY HEALTH CENTERS,INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 751 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071044309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734831300 | ||||||||
| FaxNumber: | 9734833787 | ||||||||
| Practice Location | |||||||||
| Address1: | 751 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071044309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734831300 | ||||||||
| FaxNumber: | 9734833787 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2008 | ||||||||
| LastUpdateDate: | 05/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | VELEZ | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9734831300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NEWARK COMMUNITY HEALTH CENTERS,INC. | ||||||||
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| AuthorizedOfficialCredential: | MPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 22382 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0055581 | 05 | NJ | MEDICAID |