Provider Demographics
NPI:1033268370
Name:NEW JERSEY MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:NEW JERSEY MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-503-0828
Mailing Address - Street 1:464 HUDSON TER
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-2902
Mailing Address - Country:US
Mailing Address - Phone:201-503-0828
Mailing Address - Fax:201-503-0848
Practice Address - Street 1:464 HUDSON TER
Practice Address - Street 2:SUITE 201
Practice Address - City:ENGLEWOOD CLIFFS
Practice Address - State:NJ
Practice Address - Zip Code:07632-2902
Practice Address - Country:US
Practice Address - Phone:201-503-0828
Practice Address - Fax:201-503-0848
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA53599207R00000X, 207RH0003X
NJMA45119207RC0000X
NJ43165207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6919405Medicaid
NJ559608Medicare ID - Type Unspecified