Basic Information
Provider Information | |||||||||
NPI: | 1881677904 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIN | ||||||||
FirstName: | JAI-NAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 18914 | ||||||||
Address2: |   | ||||||||
City: | NEWARK | ||||||||
State: | NJ | ||||||||
PostalCode: | 071918914 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2014880066 | ||||||||
FaxNumber: | 2014886769 | ||||||||
Practice Location | |||||||||
Address1: | 30 PROSPECT AVE | ||||||||
Address2: |   | ||||||||
City: | HACKENSACK | ||||||||
State: | NJ | ||||||||
PostalCode: | 076011914 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2014880066 | ||||||||
FaxNumber: | 2014886769 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2005 | ||||||||
LastUpdateDate: | 05/21/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 25MA03062200 | NJ | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 01594361 | 05 | NY |   | MEDICAID | 1439502 | 05 | NJ |   | MEDICAID | 41588 | 01 | NJ | AMERIGROUP | OTHER | 050057784 | 01 |   | RAILROAD MEDICARE | OTHER | 1058879 | 01 | NJ | HORIZON MERCY | OTHER |