Provider Demographics
NPI:1306500764
Name:ENNOBLE HC NJ PC
Entity type:Organization
Organization Name:ENNOBLE HC NJ PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KUSHABHADRA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-812-9010
Mailing Address - Street 1:2 UNIVERSITY PLAZA DRIVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601
Mailing Address - Country:US
Mailing Address - Phone:973-241-1356
Mailing Address - Fax:
Practice Address - Street 1:2 UNIVERSITY PLZ
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-6202
Practice Address - Country:US
Practice Address - Phone:973-435-9463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-22
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty