Provider Demographics
NPI:1245595313
Name:IMMEDIATE CARE MEDICAL WALK-IN OF HAZLET, PA
Entity Type:Organization
Organization Name:IMMEDIATE CARE MEDICAL WALK-IN OF HAZLET, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOLDING-GRANADO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-264-5500
Mailing Address - Street 1:1376 HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:HAZLET
Mailing Address - State:NJ
Mailing Address - Zip Code:07730
Mailing Address - Country:US
Mailing Address - Phone:732-264-5500
Mailing Address - Fax:732-264-5554
Practice Address - Street 1:1376 HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:HAZLET
Practice Address - State:NJ
Practice Address - Zip Code:07730
Practice Address - Country:US
Practice Address - Phone:732-264-5500
Practice Address - Fax:732-264-5554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-05
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 207R00000X
NJ261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0OtherHORIZON BLUE CROSS AND BLUE SHIELD
NJ255217Medicare PIN