Provider Demographics
NPI:1275639031
Name:IMMEDICENTER
Entity Type:Organization
Organization Name:IMMEDICENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:SQUIRLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-778-5566
Mailing Address - Street 1:1355 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07013-4221
Mailing Address - Country:US
Mailing Address - Phone:973-778-5566
Mailing Address - Fax:973-778-4044
Practice Address - Street 1:1355 BROAD ST
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07013-4221
Practice Address - Country:US
Practice Address - Phone:973-778-5566
Practice Address - Fax:973-778-4044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJCB7304OtherRAILROAD MEDICARE
NJ527877Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
NJ0995970001Medicare NSC