Basic Information
| Provider Information | |||||||||
| NPI: | 1801274634 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. JOSEPH'S HOSPITAL AND MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. JOSEPH'S REGIONAL MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 703 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PATERSON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 075032621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737542000 | ||||||||
| FaxNumber: | 9737542149 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 SULLIVAN WAY | ||||||||
| Address2: | COTTAGE 1 | ||||||||
| City: | EWING | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 086283405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096435805 | ||||||||
| FaxNumber: | 6096435507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/13/2015 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUNAY | ||||||||
| AuthorizedOfficialFirstName: | JOANNE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 9737542016 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST. JOSEPH'S HOSPITAL AND MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 0393746 | 05 | NJ | MEDICAID |