Basic Information
| Provider Information | |||||||||
| NPI: | 1437356755 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IJKG OPCO LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BAYONNE MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29TH STREET AT AVENUE E | ||||||||
| Address2: | |||||||||
| City: | BAYONNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018585000 | ||||||||
| FaxNumber: | 2018587333 | ||||||||
| Practice Location | |||||||||
| Address1: | 29TH STREET AT AVENUE E | ||||||||
| Address2: | |||||||||
| City: | BAYONNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018585000 | ||||||||
| FaxNumber: | 2018587333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 12/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | BRYANT | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO & EVP | ||||||||
| AuthorizedOfficialTelephone: | 2018218911 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 221487124 | NJ | N | Hospitals | General Acute Care Hospital | 314000000X | 315431 | NJ | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4136705 | 05 | NJ | MEDICAID |