Provider Demographics
NPI:1376799932
Name:CAG MEMORIAL HEALTH CENTER
Entity Type:Organization
Organization Name:CAG MEMORIAL HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:201-333-0094
Mailing Address - Street 1:75 HARRISON AVE
Mailing Address - Street 2:SUITE #2
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07304-2555
Mailing Address - Country:US
Mailing Address - Phone:201-333-0094
Mailing Address - Fax:201-333-6538
Practice Address - Street 1:75 HARRISON AVE
Practice Address - Street 2:SUITE #2
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07304-2555
Practice Address - Country:US
Practice Address - Phone:201-333-0094
Practice Address - Fax:201-333-6538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMAO13695207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ01000097700OtherAMERICHOICE
NJ2684403Medicaid
NJ2684403Medicaid