Provider Demographics
NPI:1578808952
Name:IRVINGTON EMERGENT CARE
Entity Type:Organization
Organization Name:IRVINGTON EMERGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RUDOLPH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-373-3000
Mailing Address - Street 1:12 KROTIK PL
Mailing Address - Street 2:
Mailing Address - City:IRVINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07111-1708
Mailing Address - Country:US
Mailing Address - Phone:973-373-3000
Mailing Address - Fax:973-399-8880
Practice Address - Street 1:12 KROTIK PL
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07111-1708
Practice Address - Country:US
Practice Address - Phone:973-373-3000
Practice Address - Fax:973-399-8880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA042750NJ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0887307Medicaid
NJ117465Medicare PIN