MEDICARE: MY NJ MEDICINE CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P5595606	OTHER	NJ	OXFORD

General Provider Information

NPI Number	:	1306318241
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MY NJ MEDICINE CORP

Provider Business Mailing Address
First Line	:	76 PROSPECT ST
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07105-1881
Country	:	US
Telephone Number	:	973-344-1313
Fax Number	:	973-900-8809

Provider Business Practice Location Address
First Line	:	76 PROSPECT ST
Second Line	:
City	:	NEWARK
State	:	NJ
Zip	:	07105-1881
Country	:	US
Telephone Number	:	973-344-1313
Fax Number	:	973-900-8809

Authorized Official
Title or Position	:	OWNER
Name	:	DR. EDUARDO SAMANIEGO
Credential	:	MD
Telephone Number	:	973-344-1313

Provider Enumeration Date	:	12/17/2018
Last Update Date	:	12/17/2018

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Directions to “MY NJ MEDICINE CORP ” Practice Location

Language	Start Address	Practice Location

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