Provider Demographics
NPI:1164528634
Name:BETH ISRAEL HOSPITAL ASSOCIATION
Entity Type:Organization
Organization Name:BETH ISRAEL HOSPITAL ASSOCIATION
Other - Org Name:PBI REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR MANGED CARE
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-365-4556
Mailing Address - Street 1:350 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-2840
Mailing Address - Country:US
Mailing Address - Phone:973-365-4300
Mailing Address - Fax:
Practice Address - Street 1:350 BOULEVARD
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-2840
Practice Address - Country:US
Practice Address - Phone:973-365-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ11604282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4136501Medicaid
NJ312329Medicare ID - Type UnspecifiedRENAL PROVIDER
NJ4136501Medicaid