=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295250462
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY MEDICAL OF NEW JERSEY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/09/2017
-----------------------------------------------------
Last Update Date | 02/19/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 609 BROAD ST
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07102-4408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | --
-----------------------------------------------------
Fax | --
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1345 RXR PLZ
-----------------------------------------------------
City | UNIONDALE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11556-1301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-783-4600
-----------------------------------------------------
Fax | 646-846-3283
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, CREDENTIALING
-----------------------------------------------------
Name | MARLENA SIMPSON
-----------------------------------------------------
Credential | CPMSM
-----------------------------------------------------
Telephone | 516-453-0435
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------