Provider Demographics
NPI:1073984654
Name:SOVEREIGN MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SOVEREIGN MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAJJAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-855-8302
Mailing Address - Street 1:85 HARRISTOWN RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-3329
Mailing Address - Country:US
Mailing Address - Phone:201-855-8301
Mailing Address - Fax:
Practice Address - Street 1:630 BROAD ST
Practice Address - Street 2:SUITE 2B
Practice Address - City:CARLSTADT
Practice Address - State:NJ
Practice Address - Zip Code:07072-1169
Practice Address - Country:US
Practice Address - Phone:201-355-1700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies