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General NPI Number Information
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NPI Number | 1326494378
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Entity Type | Organization
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Legal Business Name | PRIME HEALTHCARE SERVICES-ST MICHAELS MEDICAL GROUP LLC
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Dates
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Enumeration Date | 05/09/2016
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Last Update Date | 05/12/2016
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Provider Practice Location Address
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Address Line | 111 CENTRAL AVE
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City | NEWARK
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State | NJ
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Zip | 07102-1909
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Country | US
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Telephone | 973-854-3592
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Fax | 973-877-2434
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Provider Business Mailing Address
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Address Line | 111 CENTRAL AVE
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City | NEWARK
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State | NJ
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Zip | 07102-1909
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Country | US
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Telephone | 973-854-3592
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Fax | 973-877-2434
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Authorized Official
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Title or Position | CHIEF COMPLIANCE COUNSEL
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Name | CHRISTOPHER DOAN
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Credential |
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Telephone | 909-235-4307
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208600000X
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Taxonomy Name | Surgery Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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