Basic Information
| Provider Information | |||||||||
| NPI: | 1033152277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HALLENBECK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | P. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1345 RXR PLZ FL 13 | ||||||||
| Address2: | |||||||||
| City: | UNIONDALE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115561301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5164530435 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | PASSAIC | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070552840 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733654489 | ||||||||
| FaxNumber: | 9739162032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 07/24/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MB70972 | NJ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 284860 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 25MB07097200 | NJ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8777705 | 05 | NJ | MEDICAID | 223586664 | 01 | NJ | TRICARE/CHAMPUS | OTHER | 223586664 | 01 | NJ | BCBS | OTHER |