Provider Demographics
NPI:1083668479
Name:INFECTIOUS DISEASE GROUP OF NORTH JERSEY
Entity Type:Organization
Organization Name:INFECTIOUS DISEASE GROUP OF NORTH JERSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGHOSSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-597-0704
Mailing Address - Street 1:PO BOX 93
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-0093
Mailing Address - Country:US
Mailing Address - Phone:239-597-0704
Mailing Address - Fax:239-597-0709
Practice Address - Street 1:631 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3846
Practice Address - Country:US
Practice Address - Phone:239-597-0704
Practice Address - Fax:239-597-0704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8491305Medicaid
NJ047337Medicare ID - Type Unspecified