Healthcare Provider Details

I. General information

NPI: 1215957519
Provider Name (Legal Business Name): DEPT. OF MED, C/O CARL O'BRIEN DBA PRINCETON HOSP. MEDICAL ASSOCS.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 01/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 WITHERSPOON ST
PRINCETON NJ
08540-3211
US

IV. Provider business mailing address

4 PRINCESS RD SUITE #207
LAWRENCEVILLE NJ
08648-2322
US

V. Phone/Fax

Practice location:
  • Phone: 609-497-4000
  • Fax: 609-430-7218
Mailing address:
  • Phone: 609-734-7600
  • Fax: 609-844-1092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: KENNETH H GOLDBLATT
Title or Position: AUTHORIZED OFFICIAL
Credential: M.D.
Phone: 609-497-4000