Basic Information
| Provider Information | |||||||||
| NPI: | 1215947106 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DIGITRACE CARE SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE PL | ||||||||
| Address2: | SUITE 5B | ||||||||
| City: | PEABODY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 019603840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9785367400 | ||||||||
| FaxNumber: | 9785359757 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 S VAN BRUNT ST | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076314604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6105436800 | ||||||||
| FaxNumber: | 6105438051 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 11/23/2011 | ||||||||
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| AuthorizedOfficialLastName: | IBERGER | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | R. | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 9785367400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QS1200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Sleep Disorder Diagnostic |
ID Information
| ID | Type | State | Issuer | Description | 0658107000 | 01 | NJ | AMERIHEALTH HMO | OTHER | 0453320000 | 01 | NJ | AMERIHEALTH PERS CHOICE | OTHER | 0658107000 | 01 | NJ | KEYSTONE | OTHER | 7618325 | 01 | NJ | AETNA | OTHER |