Provider Demographics
NPI:1598050452
Name:JERSEY HEALTH CLINIC
Entity Type:Organization
Organization Name:JERSEY HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:GAMAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:HANNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-967-8425
Mailing Address - Street 1:PO BOX 8265
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-8265
Mailing Address - Country:US
Mailing Address - Phone:201-855-1200
Mailing Address - Fax:201-967-8425
Practice Address - Street 1:79 NELSON AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-4006
Practice Address - Country:US
Practice Address - Phone:201-855-1200
Practice Address - Fax:201-967-8443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-17
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05217700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1884808Medicaid