1659882082 NPI number — BMG EAST ORANGE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659882082 NPI number — BMG EAST ORANGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BMG EAST ORANGE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
URGENT CARE & WALK-IN MEDICAL SUITE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659882082
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 FREEWAY DR E STE 305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EAST ORANGE
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07018-3809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-370-4000
Provider Business Mailing Address Fax Number:
862-904-0044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 FREEWAY DR E STE 305
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST ORANGE
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-370-4000
Provider Business Practice Location Address Fax Number:
973-370-4040
Provider Enumeration Date:
10/12/2017

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBS
Authorized Official First Name:
BLIMY
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING & CREDENTIALING DIRECTOR
Authorized Official Telephone Number:
845-662-2404

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  25MA08818300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RI0200X , with the licence number: 25MA08818300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0630390 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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