Basic Information
| Provider Information | |||||||||
| NPI: | 1639210180 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDRENS SPECIALIZED HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 NEW PROVIDENCE RD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAINSIDE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070922590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082333720 | ||||||||
| FaxNumber: | 9083015456 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 NEW PROVIDENCE RD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAINSIDE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070922590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9082333720 | ||||||||
| FaxNumber: | 9083015456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DOBOSH | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, FINANCE & CFO | ||||||||
| AuthorizedOfficialTelephone: | 9083015455 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | 22249 | NJ | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment |
ID Information
| ID | Type | State | Issuer | Description | 01000192906 | 01 | NJ | AMERIHEALTH | OTHER | 1025388 | 01 | NJ | HORIZON NJ HEALTH | OTHER | 313300 | 01 | NJ | HORIZON BCBS | OTHER | 0778139002 | 01 | NJ | AMERIHEALTH | OTHER | 10832 | 01 | NJ | UNIVERSITY HEALTH PLANS | OTHER | 01000192900 | 01 | NJ | AMERIHEALTH | OTHER | IL5516 | 01 | NJ | HEALTHNET | OTHER | 99853 | 01 | NJ | AMERIGROUP | OTHER | HO1318 | 01 | NJ | OXFORD HEALTH PLANS | OTHER | 01000192903 | 01 | NJ | AMERIHEALTH | OTHER | 1621 | 01 | NJ | EMPIRE | OTHER |