Basic Information
Provider Information | |||||||||
NPI: | 1114101607 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HENRY J AUSTIN HEALTH CENTER, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 112 EWING ST | ||||||||
Address2: |   | ||||||||
City: | TRENTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 086091004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6093969600 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 112 EWING ST | ||||||||
Address2: |   | ||||||||
City: | TRENTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 086091004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6093969600 | ||||||||
FaxNumber: | 6096953532 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/20/2007 | ||||||||
LastUpdateDate: | 06/03/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOYKIN | ||||||||
AuthorizedOfficialFirstName: | ANNE | ||||||||
AuthorizedOfficialMiddleName: | A. | ||||||||
AuthorizedOfficialTitleorPosition: | COLLECTION/CREDENTIAL MANAGER | ||||||||
AuthorizedOfficialTelephone: | 6092785976 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 22436 | NJ | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.