Basic Information
| Provider Information | |||||||||
| NPI: | 1710199468 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JEWISH RENAISSANCE MEDICAL CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1220 | ||||||||
| Address2: | |||||||||
| City: | PERTH AMBOY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088621220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323766635 | ||||||||
| FaxNumber: | 7323245765 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 JOHNSON AVE | ||||||||
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| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071082729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9736238592 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2007 | ||||||||
| LastUpdateDate: | 10/20/2009 | ||||||||
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| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7323766601 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 23975 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0097918 | 05 | NJ | MEDICAID | 0751103 | 05 | NJ | MEDICAID | 8932603 | 05 | NJ | MEDICAID | 0115045 | 05 | NJ | MEDICAID | 8462500 | 05 | NJ | MEDICAID |