Basic Information
| Provider Information | |||||||||
| NPI: | 1902844806 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLINICAL HEALTH CARE ASSOCIATES OF NEW JERSEY, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 51 N 39TH ST | ||||||||
| Address2: | PRESBYTERIAN MEDICAL CENTER, 4 HVP | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156629189 | ||||||||
| FaxNumber: | 2152434612 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 N 39TH ST | ||||||||
| Address2: | PRESBYTERIAN MEDICAL CENTER, 4 HVP | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191042640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156629189 | ||||||||
| FaxNumber: | 2152434612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | CHANTE | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ENROLLMENT LEAD | ||||||||
| AuthorizedOfficialTelephone: | 2156626187 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0016653070003 | 05 | PA | MEDICAID |