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General NPI Number Information
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NPI Number | 1245642669
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Entity Type | Organization
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Legal Business Name | ST MARY'S HOSPITAL
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Dates
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Enumeration Date | 05/21/2014
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Last Update Date | 05/21/2014
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Provider Practice Location Address
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Address Line | 350 MAIN AVE
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City | PASSAIC
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State | NJ
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Zip | 07055
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Country | US
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Telephone | 973-470-3056
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Fax |
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Provider Business Mailing Address
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Address Line | 350 MAIN AVE
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City | PASSAIC
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State | NJ
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Zip | 07055
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Country | US
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Telephone | 973-470-3056
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Fax |
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Authorized Official
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Title or Position | ED
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Name | MR. PERRY IASELLO
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Credential | LCSW
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Telephone | 973-470-3056
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 283Q00000X
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Taxonomy Name | Psychiatric Hospital
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License Number | 37LC00086000
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License Number State | NJ
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