Provider Demographics
NPI:1225240971
Name:JEWISH RENAISSANCE MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:JEWISH RENAISSANCE MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-376-6601
Mailing Address - Street 1:PO BOX 1220
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08862-1220
Mailing Address - Country:US
Mailing Address - Phone:732-376-6635
Mailing Address - Fax:732-324-5765
Practice Address - Street 1:226 DAYTON ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07114-1159
Practice Address - Country:US
Practice Address - Phone:973-733-8781
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ23981261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0751103Medicaid
NJ8462500Medicaid
NJ0097845Medicaid
NJ0115045Medicaid
NJ8932603Medicaid
NJ0115045Medicaid
NJ8932603Medicaid
NJ047027Q3JMedicare PIN
NJ0097845Medicaid
NJ8462500Medicaid