Healthcare Provider Details

I. General information

NPI: 1871475806
Provider Name (Legal Business Name): ENNOBLE HC NJ II PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2025
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 UNIVERSITY PLZ STE 204
HACKENSACK NJ
07601-6211
US

IV. Provider business mailing address

2 UNIVERSITY PLZ STE 204
HACKENSACK NJ
07601-6211
US

V. Phone/Fax

Practice location:
  • Phone: 551-295-8223
  • Fax:
Mailing address:
  • Phone: 551-295-8223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family 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: MARK BRADSHAW
Title or Position: OWNER
Credential: MD
Phone: 678-665-2618