Healthcare Provider Details

I. General information

NPI: 1275356560
Provider Name (Legal Business Name): THE COLLABORATIVE HEALTHCARE GROUP OF NJ
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2024
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1598 RTE 130
NORTH BRUNSWICK NJ
08902-3040
US

IV. Provider business mailing address

5 STONE HILL RD
MANAHAWKIN NJ
08050-5618
US

V. Phone/Fax

Practice location:
  • Phone: 877-328-7112
  • Fax: 877-260-9979
Mailing address:
  • Phone: 877-328-7112
  • Fax: 877-260-9979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State
# 10
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KEVIN SCOTT MACNIVEN
Title or Position: CEO
Credential: MBA
Phone: 877-328-7112