Basic Information
| Provider Information | |||||||||
| NPI: | 1780632992 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT BARNABAS MULTI SPECIALTY | ||||||||
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| OtherOrganizationName: | SBMC MULTI SPECIALTY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 18340 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071918340 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8662950041 | ||||||||
| FaxNumber: | 7325577109 | ||||||||
| Practice Location | |||||||||
| Address1: | 94 OLD SHORT HILLS RD | ||||||||
| Address2: | |||||||||
| City: | LIVINGSTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070395672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9733225690 | ||||||||
| FaxNumber: | 9733225504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 07/09/2008 | ||||||||
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| AuthorizedOfficialLastName: | AHEARN | ||||||||
| AuthorizedOfficialFirstName: | PATRICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7325577119 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0210X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Nephrology | 2080P0208X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0203X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7653204 | 05 | NJ | MEDICAID |