Basic Information
| Provider Information | |||||||||
| NPI: | 1972778413 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NEWARK COMMUNITY HEALTH CENTERS INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | IRVINGTON COMMUNITY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 741 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071044309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9734831300 | ||||||||
| FaxNumber: | 9734833787 | ||||||||
| Practice Location | |||||||||
| Address1: | 1148 - 1150 SPRINGFIELD AVENUE | ||||||||
| Address2: | |||||||||
| City: | IRVINGTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071112441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733996292 | ||||||||
| FaxNumber: | 9733724534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2008 | ||||||||
| LastUpdateDate: | 09/18/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLARKE | ||||||||
| AuthorizedOfficialFirstName: | PAMELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9734831300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NEWARK COMMUNITY HEALTH CENTERS INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DOCTORATE | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | 23134 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 0179965 | 05 | NJ | MEDICAID | 23134 | 01 | NJ | STATE LICENSE | OTHER |