Basic Information
| Provider Information | |||||||||
| NPI: | 1720014830 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OLD HOOK MEDICAL ASSOCIATES, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OLD HOOK MEDICAL ASSOCIATES SURGICENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 452 OLD HOOK RD | ||||||||
| Address2: | |||||||||
| City: | EMERSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076301381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2016663900 | ||||||||
| FaxNumber: | 2012610505 | ||||||||
| Practice Location | |||||||||
| Address1: | 452 OLD HOOK RD | ||||||||
| Address2: | |||||||||
| City: | EMERSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076301381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2016663900 | ||||||||
| FaxNumber: | 2012610505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2006 | ||||||||
| LastUpdateDate: | 05/31/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LIJO | ||||||||
| AuthorizedOfficialFirstName: | JAIME | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING/CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 2016663900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OLD HOOK MEDICAL ASSOCIATES LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CCS-P | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 1092980 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.