Basic Information
| Provider Information | |||||||||
| NPI: | 1760492367 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY PHYSICIAN ASSOCIATES OF NEW JERSEY INC | ||||||||
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| OtherOrganizationName: | UNIVERSITY MEDICAL ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 BERGEN STREET | ||||||||
| Address2: | ADMC 12 1205 | ||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071073000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739720037 | ||||||||
| FaxNumber: | 9739729355 | ||||||||
| Practice Location | |||||||||
| Address1: | 140 BERGEN ST | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9739729000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 08/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | HAIER | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9739729503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2814722 | 05 | NJ | MEDICAID |