Basic Information
| Provider Information | |||||||||
| NPI: | 1326646019 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY MEDICAL ASSOCIATES (OM) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 BERGEN ST # 1205 | ||||||||
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| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071073000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739725004 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 LYONS AVE | ||||||||
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| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071122027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739267000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2020 | ||||||||
| LastUpdateDate: | 10/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | HAIER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9739729503 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPECIAL LLC | ||||||||
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| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.