Provider Demographics
NPI:1659749844
Name:PASSAIC MEDICAL CARE INC
Entity Type:Organization
Organization Name:PASSAIC MEDICAL CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:MARCOTULLI
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:862-238-8181
Mailing Address - Street 1:1135 MAIN AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CLIFTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07011-2353
Mailing Address - Country:US
Mailing Address - Phone:862-238-8181
Mailing Address - Fax:862-238-8183
Practice Address - Street 1:1135 MAIN AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2353
Practice Address - Country:US
Practice Address - Phone:862-238-8181
Practice Address - Fax:862-238-8183
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-04
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00587800363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ26NJ00587800OtherMEDICAL LICENSE