Provider Demographics
NPI:1083747299
Name:CENTER FOR PREVENTATIVE MEDICINE OF NEW JERSEY
Entity Type:Organization
Organization Name:CENTER FOR PREVENTATIVE MEDICINE OF NEW JERSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-762-6077
Mailing Address - Street 1:5 STANLEY RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2721
Mailing Address - Country:US
Mailing Address - Phone:973-762-6077
Mailing Address - Fax:
Practice Address - Street 1:5 STANLEY RD
Practice Address - Street 2:
Practice Address - City:SOUTH ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07079-2721
Practice Address - Country:US
Practice Address - Phone:973-762-6077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04662500207Q00000X
NJ25MA04002500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ=========OtherTAX ID
NJ073942Medicare PIN