Basic Information
| Provider Information | |||||||||
| NPI: | 1689682478 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | U.S. DEPT. OF VETERANS AFFAIRS | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | V.A. N.J. HEALTH CARE SYSTEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 KNOLLCROFT RD | ||||||||
| Address2: | BUILDING 143,ROOM WII8 | ||||||||
| City: | LYONS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079395001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9086470180 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 155 KNOLLCROFT RD | ||||||||
| Address2: | BUILDING 143,ROOM WII8 | ||||||||
| City: | LYONS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 079395001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9086470180 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | IM | ||||||||
| AuthorizedOfficialFirstName: | CHAE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF,PHYSICAL MEDICINE REHAB SERVI | ||||||||
| AuthorizedOfficialTelephone: | 9736761000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | 46TR00254000 | NJ | Y | Hospitals | Psychiatric Hospital |
No ID Information.