=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194761502
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BAYONNE EMERGENCY ASSOC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29 EAST 29TH STREET
-----------------------------------------------------
City | BAYONNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-858-5000
-----------------------------------------------------
Fax | 856-616-1919
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5075
-----------------------------------------------------
City | CHERRY HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08034-5075
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-616-8100
-----------------------------------------------------
Fax | 856-616-7919
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DAVID ISTVAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 201-858-5000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QE0002X
-----------------------------------------------------
Taxonomy Name | Emergency Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------