Provider Demographics
NPI:1063670578
Name:IMMEDI-CARE PA
Entity Type:Organization
Organization Name:IMMEDI-CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:MS
Authorized Official - First Name:DIMITRA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:PALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-874-9084
Mailing Address - Street 1:PO BOX 1296
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07012-0796
Mailing Address - Country:US
Mailing Address - Phone:973-643-8383
Mailing Address - Fax:973-491-6099
Practice Address - Street 1:360 AVENUE P FL 3
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07105
Practice Address - Country:US
Practice Address - Phone:973-643-8383
Practice Address - Fax:973-491-6099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJE15297Medicare UPIN
NJ184628Medicare PIN