Provider Demographics
NPI:1477686871
Name:HOLY NAME MEDICAL CENTER INC
Entity Type:Organization
Organization Name:HOLY NAME MEDICAL CENTER INC
Other - Org Name:HOLY NAME HOSPITAL HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP & CFO
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-833-7016
Mailing Address - Street 1:718 TEANECK RD
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4245
Mailing Address - Country:US
Mailing Address - Phone:201-833-3188
Mailing Address - Fax:201-530-7900
Practice Address - Street 1:718 TEANECK RD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4245
Practice Address - Country:US
Practice Address - Phone:201-833-3188
Practice Address - Fax:201-530-7900
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOLY NAME MEDICAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-14
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22759251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9030000Medicaid
NJ9030000Medicaid
NJ311547Medicare Oscar/Certification
NJ311547Medicare UPIN