=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679299689
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONCERTOCARE MEDICAL GROUP OF NEW JERSEY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2022
-----------------------------------------------------
Last Update Date | 10/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 215 FENWAY RD
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43214-1409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-969-4746
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 801280
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64180-1280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-553-3591
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JAMES L HUNTER
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 313-969-4746
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------