=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760989669
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOBILE MEDICAL SERVICES OF NEW JERSEY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2018
-----------------------------------------------------
Last Update Date | 04/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1807 FAULKNER CT
-----------------------------------------------------
City | MAHWAH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07430-3491
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-889-4395
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1807 FAULKNER COURT
-----------------------------------------------------
City | MAHWAH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | DONNA MCMACKIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-889-4395
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------