Provider Demographics
NPI:1477744555
Name:PODIATRY ASSOCIATES OF ENGLEWOOD NJ PC
Entity Type:Organization
Organization Name:PODIATRY ASSOCIATES OF ENGLEWOOD NJ PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-568-6977
Mailing Address - Street 1:363 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4104
Mailing Address - Country:US
Mailing Address - Phone:201-568-6977
Mailing Address - Fax:201-568-7567
Practice Address - Street 1:363 GRAND AVE
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4104
Practice Address - Country:US
Practice Address - Phone:201-568-6977
Practice Address - Fax:201-568-7567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD1961213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0452298000OtherAMERIHEALTH
NJ0063356OtherGHI ID#
NJ0110120OtherAETNA ID#
NJ2139688OtherCIGNA ID#
NJJ32278OtherHEALTHNET ID#
NJ6198104Medicaid
NJP1023259OtherOXFORD ID#
NJ0452298000OtherAMERIHEALTH
NJ6198104Medicaid