=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144641028
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHIATRIC CONSULTATION PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/19/2013
-----------------------------------------------------
Last Update Date | 01/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 122 PLANE ST 1A
-----------------------------------------------------
City | BOONTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07005-1760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-224-5509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 122 PLANE ST 1A
-----------------------------------------------------
City | BOONTON
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07005-1760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-224-5509
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. GHULAM MURTAZA BAJWA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 973-224-5509
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 25MA09089100
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------