Basic Information
| Provider Information | |||||||||
| NPI: | 1710454442 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | URGENT ORTHO CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076314104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018339500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 403 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | ENGLEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076314104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018339500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2018 | ||||||||
| LastUpdateDate: | 10/31/2018 | ||||||||
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| AuthorizedOfficialLastName: | BARUCH | ||||||||
| AuthorizedOfficialFirstName: | HOWARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2016470254 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PREMIER ORTHOPAEDICS &SPORTS MEDICINE,PC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 1417387572 | 01 | NJ | ALIZA BLACK | OTHER |