Healthcare Provider Details

I. General information

NPI: 1598050452
Provider Name (Legal Business Name): JERSEY HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2011
Last Update Date: 06/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 NELSON AVE
JERSEY CITY NJ
07307-4006
US

IV. Provider business mailing address

PO BOX 8265
NORTH BERGEN NJ
07047-8265
US

V. Phone/Fax

Practice location:
  • Phone: 201-855-1200
  • Fax: 201-967-8443
Mailing address:
  • Phone: 201-855-1200
  • Fax: 201-967-8425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA05217700
License Number StateNJ

VIII. Authorized Official

Name: GAMAL K HANNA
Title or Position: MD
Credential: M.D.
Phone: 201-967-8425