Basic Information
| Provider Information | |||||||||
| NPI: | 1285834069 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HOSPITAL GROUP, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JFK DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 JAMES ST | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | EDISON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088203938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323217000 | ||||||||
| FaxNumber: | 7326321644 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 JAMES ST | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | EDISON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088203938 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323217000 | ||||||||
| FaxNumber: | 7326321644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2007 | ||||||||
| LastUpdateDate: | 07/20/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | AUGUSTINE | ||||||||
| AuthorizedOfficialFirstName: | TONI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR BILLING SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7323217000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | COMMUNITY HOSPITAL GROUP, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MISS | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 22293 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 3676811 | 05 | NJ | MEDICAID |