Healthcare Provider Details

I. General information

NPI: 1467849364
Provider Name (Legal Business Name): COMPREHENSIVE NEPHROLOGY OF NORTHERN NEW JERSEY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 E RIDGEWOOD AVE BLDG. 6 2ND FLOOR
PARAMUS NJ
07652-4142
US

IV. Provider business mailing address

PO BOX 157
FRANKLIN LAKES NJ
07417-0157
US

V. Phone/Fax

Practice location:
  • Phone: 201-225-4700
  • Fax: 201-225-4702
Mailing address:
  • Phone: 201-967-8425
  • Fax: 201-263-4665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number25MA08621600
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: ADAEZE IBEABUCHI
Title or Position: M.D.
Credential: M.D.
Phone: 201-967-8425