Healthcare Provider Details

I. General information

NPI: 1881677904
Provider Name (Legal Business Name): JAI-NAN LIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 05/21/2008
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: 201-488-6769
Mailing address:
  • Phone: 201-488-0066
  • Fax: 201-488-6769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number25MA03062200
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01594361
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 2
Identifier1439502
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 3
Identifier41588
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerAMERIGROUP
# 4
Identifier050057784
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE
# 5
Identifier1058879
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerHORIZON MERCY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: