Basic Information
Provider Information | |||||||||
NPI: | 1922194216 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | RUTGERS HEALTH-RWJ NEUROSURGERY FACULTY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RUTGERS HEALTH-RWJ SURGICAL CRITICAL CARE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 66 W GILBERT ST | ||||||||
Address2: |   | ||||||||
City: | RED BANK | ||||||||
State: | NJ | ||||||||
PostalCode: | 07701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322120051 | ||||||||
FaxNumber: | 7322120713 | ||||||||
Practice Location | |||||||||
Address1: | 1 ROBERT WOOD JOHNSON PL | ||||||||
Address2: |   | ||||||||
City: | NEW BRUNSWICK | ||||||||
State: | NJ | ||||||||
PostalCode: | 089011928 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7322357920 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/05/2006 | ||||||||
LastUpdateDate: | 01/20/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LAWRENCE | ||||||||
AuthorizedOfficialFirstName: | BRENDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 7322356070 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/20/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
ID | Type | State | Issuer | Description | 7959605 | 05 | NJ |   | MEDICAID |