Healthcare Provider Details

I. General information

NPI: 1730406414
Provider Name (Legal Business Name): HUMC MEDICAL OBSERVATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE EMERGENCY MEDICINE
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

30 PROSPECT AVE PB TRAILER
HACKENSACK NJ
07601-1914
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-5045
  • Fax:
Mailing address:
  • Phone: 551-996-5045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DR. IHOR SAWCZUK
Title or Position: PRESIDENT
Credential: MD
Phone: 201-996-3600