Basic Information
| Provider Information | |||||||||
| NPI: | 1235271206 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEWARK COMMUNITY HEALTH CENTERS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 741 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071044309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734831300 | ||||||||
| FaxNumber: | 9734831876 | ||||||||
| Practice Location | |||||||||
| Address1: | 741 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071044309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734831300 | ||||||||
| FaxNumber: | 9734831876 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/13/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSON | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 9734831300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | 70777 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | MA37886 | 01 | NJ | STATE LICENSE | OTHER |