Basic Information
Provider Information | |||||||||
NPI: | 1336221878 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STATE OF NEW JERSEY OMB CENTRALIZED PAYROLL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GREYSTONE PARK PSYCHIATRIC HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 59 KOCH AVE | ||||||||
Address2: |   | ||||||||
City: | MORRIS PLAINS | ||||||||
State: | NJ | ||||||||
PostalCode: | 079504400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9735381800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 59 KOCH AVE | ||||||||
Address2: |   | ||||||||
City: | MORRIS PLAINS | ||||||||
State: | NJ | ||||||||
PostalCode: | 079504400 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9735381800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/20/2006 | ||||||||
LastUpdateDate: | 03/23/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | NURENBERG | ||||||||
AuthorizedOfficialFirstName: | JEFFRY | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 9732924003 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | 283Q00000X | NJ | Y |   | Hospitals | Psychiatric Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 692715 | 01 |   | MEDICARE BUILDING GROUP N | OTHER |