Basic Information
| Provider Information | |||||||||
| NPI: | 1730508250 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRIME HEALTHCARE SERVICES - ST. MARY'S PASSAIC, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. MARY'S HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 E GUASTI RD | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917618655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092354311 | ||||||||
| FaxNumber: | 9092354419 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | PASSAIC | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070552840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733654300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2014 | ||||||||
| LastUpdateDate: | 10/29/2015 | ||||||||
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| AuthorizedOfficialLastName: | SCHELL | ||||||||
| AuthorizedOfficialFirstName: | TROY | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY, GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 9092354311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | ESQ. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.