Basic Information
| Provider Information | |||||||||
| NPI: | 1578665048 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OPTUM MEDICAL CARE OF NEW JERSEY PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RIVERSIDE PEDIATRIC GROUP | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 HARMON PLZ FL 10 | ||||||||
| Address2: | |||||||||
| City: | SECAUCUS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070942803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2016367233 | ||||||||
| FaxNumber: | 2015522358 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 HARMON PLZ FL 10 | ||||||||
| Address2: | |||||||||
| City: | SECAUCUS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070942803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2016367233 | ||||||||
| FaxNumber: | 2015522358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2006 | ||||||||
| LastUpdateDate: | 09/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | BRAHMBHATT | ||||||||
| AuthorizedOfficialFirstName: | GAURANG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 2016367233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 09/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | NJ | N | Suppliers | Durable Medical Equipment & Medical Supplies | 207R00000X | 25MA08407900 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 25MA03363500 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 9088008 | 05 | NJ | MEDICAID |