Basic Information
Provider Information | |||||||||
NPI: | 1255742243 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EXCEL URGENT CARE OF NJ | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 484 TEMPLE HILL RD | ||||||||
Address2: | SUITE 104 | ||||||||
City: | NEW WINDSOR | ||||||||
State: | NY | ||||||||
PostalCode: | 125535557 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8455653700 | ||||||||
FaxNumber: | 8455653696 | ||||||||
Practice Location | |||||||||
Address1: | 2624 HIGHWAY 516 | ||||||||
Address2: |   | ||||||||
City: | OLD BRIDGE | ||||||||
State: | NJ | ||||||||
PostalCode: | 088572306 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7329525000 | ||||||||
FaxNumber: | 7329525005 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/13/2014 | ||||||||
LastUpdateDate: | 12/15/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUVO | ||||||||
AuthorizedOfficialFirstName: | ANTHONY | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
AuthorizedOfficialTelephone: | 8455653700 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
ID | Type | State | Issuer | Description | 0429198 | 05 | NJ |   | MEDICAID |