Basic Information
Provider Information | |||||||||
NPI: | 1831575406 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIMARY CARE OF ORADELL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 718 TEANECK RD | ||||||||
Address2: | ATTN: HEALTH PARTNER SERVICES | ||||||||
City: | TEANECK | ||||||||
State: | NJ | ||||||||
PostalCode: | 076664245 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2018333000 | ||||||||
FaxNumber: | 2012276207 | ||||||||
Practice Location | |||||||||
Address1: | 870 PALISADE AVE STE 205 | ||||||||
Address2: |   | ||||||||
City: | TEANECK | ||||||||
State: | NJ | ||||||||
PostalCode: | 076663445 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2018333086 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/06/2015 | ||||||||
LastUpdateDate: | 09/14/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JARRETT | ||||||||
AuthorizedOfficialFirstName: | ADAM | ||||||||
AuthorizedOfficialMiddleName: | D. | ||||||||
AuthorizedOfficialTitleorPosition: | C.M.O. | ||||||||
AuthorizedOfficialTelephone: | 2018333000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
No ID Information.