Healthcare Provider Details

I. General information

NPI: 1649904772
Provider Name (Legal Business Name): HACKENSACK MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2022
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

341 ESSEX ST
HACKENSACK NJ
07601-2048
US

IV. Provider business mailing address

483 S ORANGE AVE
SOUTH ORANGE NJ
07079-2642
US

V. Phone/Fax

Practice location:
  • Phone: 973-234-0779
  • Fax: 973-453-8059
Mailing address:
  • Phone: 973-234-0779
  • Fax: 973-453-8059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal 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. LIONEL ANICETTE JR.
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 973-234-0779