Provider Demographics
NPI:1578665048
Name:OPTUM MEDICAL CARE OF NEW JERSEY PC
Entity Type:Organization
Organization Name:OPTUM MEDICAL CARE OF NEW JERSEY PC
Other - Org Name:RIVERSIDE PEDIATRIC GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:GAURANG
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAHMBHATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-636-7233
Mailing Address - Street 1:1 HARMON PLZ FL 10
Mailing Address - Street 2:
Mailing Address - City:SECAUCUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07094-2803
Mailing Address - Country:US
Mailing Address - Phone:201-636-7233
Mailing Address - Fax:201-552-2358
Practice Address - Street 1:1 HARMON PLZ FL 10
Practice Address - Street 2:
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-2803
Practice Address - Country:US
Practice Address - Phone:201-636-7233
Practice Address - Fax:201-552-2358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-03
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08407900207R00000X
NJ25MA03363500208000000X
NJ332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9088008Medicaid