Basic Information
| Provider Information | |||||||||
| NPI: | 1497224869 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 BERGEN ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071032496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739720882 | ||||||||
| FaxNumber: | 9739729129 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 BERGEN ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071032496 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739720882 | ||||||||
| FaxNumber: | 9739729129 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2018 | ||||||||
| LastUpdateDate: | 11/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | HUCK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | GARY | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9739720882 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 3677001 | 05 | NJ | MEDICAID |