Basic Information
| Provider Information | |||||||||
| NPI: | 1073523676 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY PHYSICIAN ASSOCIATES OF NEW JERSEY INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UNIVERSITY NEURO-OPHTHALMOLOGY ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 BERGEN ST | ||||||||
| Address2: | ADMC 121205 | ||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071073000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739720037 | ||||||||
| FaxNumber: | 9739729355 | ||||||||
| Practice Location | |||||||||
| Address1: | 90 BERGEN ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071032425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739722020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 07/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | HAIER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9739729503 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY PHYSICIAN ASSOCIATES OF NEW JERSEY INC | ||||||||
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| NPICertificationDate: | 07/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 3434303 | 05 | NJ | MEDICAID |