Basic Information
| Provider Information | |||||||||
| NPI: | 1568829448 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINICAL PRACTICE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 BERGEN ST | ||||||||
| Address2: | RM 1205 | ||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071073000 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 90 BERGEN ST | ||||||||
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| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071032425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739725004 | ||||||||
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| ProviderEnumerationDate: | 01/22/2016 | ||||||||
| LastUpdateDate: | 01/22/2016 | ||||||||
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| AuthorizedOfficialLastName: | SAULICH | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR & CEO | ||||||||
| AuthorizedOfficialTelephone: | 9739725004 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.