Basic Information
| Provider Information | |||||||||
| NPI: | 1598090292 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JEWISH RENAISSANCE MEDICAL CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1220 | ||||||||
| Address2: | |||||||||
| City: | PERTH AMBOY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088621220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323766635 | ||||||||
| FaxNumber: | 7323245765 | ||||||||
| Practice Location | |||||||||
| Address1: | 275 HOBART ST | ||||||||
| Address2: | MOBILE UNIT | ||||||||
| City: | PERTH AMBOY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088614310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323769333 | ||||||||
| FaxNumber: | 7323245765 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2009 | ||||||||
| LastUpdateDate: | 10/21/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7323769333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 24332 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0152536 | 05 | NJ | MEDICAID | 7849404 | 05 | NJ | MEDICAID | 0124869 | 05 | NJ | MEDICAID | 0137616 | 05 | NJ | MEDICAID | 0193771 | 05 | NJ | MEDICAID | 0200841 | 05 | NJ | MEDICAID | 8462500 | 05 | NJ | MEDICAID | 0207161 | 05 | NJ | MEDICAID | 0158232 | 05 | NJ | MEDICAID | 0183252 | 05 | NJ | MEDICAID | 0193763 | 05 | NJ | MEDICAID | 1342304 | 05 | NJ | MEDICAID |