Basic Information
| Provider Information | |||||||||
| NPI: | 1740649268 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VMG JERSEY CITY | ||||||||
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| OtherOrganizationName: | VANGUARD MEDICAL GROUP, PA | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 700 ROUTE 46 E | ||||||||
| Address2: | SUITE 450 | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070041591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735593701 | ||||||||
| FaxNumber: | 9735598650 | ||||||||
| Practice Location | |||||||||
| Address1: | 127 MONTGOMERY ST | ||||||||
| Address2: | |||||||||
| City: | JERSEY CITY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 073023616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735593701 | ||||||||
| FaxNumber: | 9735598650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2016 | ||||||||
| LastUpdateDate: | 02/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | EIDUS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9735593701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VANGUARD MEDICAL GROUP, PA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.