Basic Information
| Provider Information | |||||||||
| NPI: | 1295876191 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDRENS SPECIALIZED HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILDRENS SPECIALIZED HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15391 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071925391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9083015900 | ||||||||
| FaxNumber: | 9083015934 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 NEW PROVIDENCE RD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAINSIDE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070922590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082333720 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 09/19/2012 | ||||||||
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| AuthorizedOfficialLastName: | DOBOSH | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE CFO | ||||||||
| AuthorizedOfficialTelephone: | 9083015455 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 22249L | NJ | N | Hospitals | Long Term Care Hospital | 3336I0012X | 28RS00417300 | NJ | N | Suppliers | Pharmacy | Institutional Pharmacy | 3336L0003X | N | Suppliers | Pharmacy | Long Term Care Pharmacy | 282E00000X | 22248L | NJ | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 3119319 | 01 | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 4439902 | 05 | NJ | MEDICAID | 4505221 | 05 | NJ | MEDICAID | 4505204 | 05 | NJ | MEDICAID |