Basic Information
Provider Information | |||||||||
NPI: | 1669462420 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST JOSEPHS UNIVERSITY MEDICAL CENTER INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ST JOSEPHS HOSPITAL AND MEDICAL CENTER | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 703 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | PATERSON | ||||||||
State: | NJ | ||||||||
PostalCode: | 075032621 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9737542000 | ||||||||
FaxNumber: | 9737542149 | ||||||||
Practice Location | |||||||||
Address1: | 703 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | PATERSON | ||||||||
State: | NJ | ||||||||
PostalCode: | 075032621 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9737542000 | ||||||||
FaxNumber: | 9737542149 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2005 | ||||||||
LastUpdateDate: | 03/31/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CAULFIELD | ||||||||
AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR, FINANCE | ||||||||
AuthorizedOfficialTelephone: | 9737542016 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 11605 | NJ | N |   | Ambulatory Health Care Facilities | Clinic/Center |   | 282N00000X | 11605 | NJ | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 4136403 | 05 | NJ |   | MEDICAID |