Basic Information
Provider Information | |||||||||
NPI: | 1124420914 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOHN | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | BRUCE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | JR. | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 122 WASHINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | MATAWAN | ||||||||
State: | NJ | ||||||||
PostalCode: | 077472922 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7329708911 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1945 RTE 33 | ||||||||
Address2: |   | ||||||||
City: | NEPTUNE | ||||||||
State: | NJ | ||||||||
PostalCode: | 077534859 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7327762325 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2014 | ||||||||
LastUpdateDate: | 09/23/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 26NO11736900 | NJ | Y |   | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
ID | Type | State | Issuer | Description | 1942208137 | 01 | NJ | JSUMC | OTHER |