Provider Demographics
NPI:1144393794
Name:UMDNJ RWJ TOBACCO DEPENDENCE PROGRAM
Entity Type:Organization
Organization Name:UMDNJ RWJ TOBACCO DEPENDENCE PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PENZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-212-0061
Mailing Address - Street 1:66 W GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701
Mailing Address - Country:US
Mailing Address - Phone:732-212-0051
Mailing Address - Fax:732-212-0713
Practice Address - Street 1:317 GEORGE ST
Practice Address - Street 2:SUITE 210
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-2008
Practice Address - Country:US
Practice Address - Phone:732-235-8222
Practice Address - Fax:732-235-8298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ097097Medicare ID - Type Unspecified