Healthcare Provider Details

I. General information

NPI: 1306087705
Provider Name (Legal Business Name): JORDAN GRANT VAN BEEVER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2009
Last Update Date: 09/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

PO BOX 18914
NEWARK NJ
07191-8914
US

V. Phone/Fax

Practice location:
  • Phone: 201-488-0066
  • Fax:
Mailing address:
  • Phone: 201-488-0066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA08576300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: