Basic Information
| Provider Information | |||||||||
| NPI: | 1851540025 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTICARE REGIONAL MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | ARMC FACULTY PRACTICE/PSY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1026 | ||||||||
| Address2: | |||||||||
| City: | PLEASANTVILLE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082326026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092728580 | ||||||||
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| Practice Location | |||||||||
| Address1: | 65 W JIMMIE LEEDS RD | ||||||||
| Address2: | PSYCHIATRY DEPT. | ||||||||
| City: | POMONA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 082409102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096523551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2008 | ||||||||
| LastUpdateDate: | 09/12/2008 | ||||||||
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| AuthorizedOfficialLastName: | NOLAN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 6095697040 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.