Basic Information
| Provider Information | |||||||||
| NPI: | 1184601288 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INSPIRA MEDICAL CENTER WOODBURY, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | UNDERWOOD-MEMORIAL HOSPITAL, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080961617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568450100 | ||||||||
| FaxNumber: | 8563841358 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 N BROAD ST | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080961617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568450100 | ||||||||
| FaxNumber: | 8563841358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2005 | ||||||||
| LastUpdateDate: | 05/16/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GRAHAM | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT COO | ||||||||
| AuthorizedOfficialTelephone: | 8568450100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | NJ | N | Hospitals | General Acute Care Hospital | 282N00000X | 10801 | NJ | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 3676102 | 05 | NJ | MEDICAID |