Healthcare Provider Details

I. General information

NPI: 1104005057
Provider Name (Legal Business Name): STATE OF NEW JERSEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2007
Last Update Date: 10/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS WAY
PARAMUS NJ
07652-4100
US

IV. Provider business mailing address

1 VETERANS WAY
PARAMUS NJ
07652-4100
US

V. Phone/Fax

Practice location:
  • Phone: 201-634-8509
  • Fax: 201-967-8658
Mailing address:
  • Phone: 201-634-8509
  • Fax: 201-967-8658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. GERARD FEENAN
Title or Position: CFO
Credential:
Phone: 201-634-8509