Healthcare Provider Details

I. General information

NPI: 1659882082
Provider Name (Legal Business Name): BMG EAST ORANGE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FREEWAY DR E STE 305
EAST ORANGE NJ
07018
US

IV. Provider business mailing address

200 FREEWAY DR E STE 305
EAST ORANGE NJ
07018-3809
US

V. Phone/Fax

Practice location:
  • Phone: 973-370-4000
  • Fax: 973-370-4040
Mailing address:
  • Phone: 973-370-4000
  • Fax: 862-904-0044

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA08818300
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number25MA08818300
License Number StateNJ

VIII. Authorized Official

Name: MS. BLIMY JACOBS
Title or Position: BILLING & CREDENTIALING DIRECTOR
Credential: CREDENTIAL
Phone: 845-662-2404