Provider Demographics
NPI: | 1710282082 |
---|---|
Name: | SOVEREIGN MEDICAL GROUP LLC |
Entity Type: | Organization |
Organization Name: | SOVEREIGN MEDICAL GROUP LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | CEO |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JOHN |
Authorized Official - Middle Name: | H |
Authorized Official - Last Name: | HAJJAR |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 201-834-1100 |
Mailing Address - Street 1: | 680 KINDERKAMACK RD |
Mailing Address - Street 2: | SUITE 300 3RD FLOOR |
Mailing Address - City: | ORADELL |
Mailing Address - State: | NJ |
Mailing Address - Zip Code: | 07649-1600 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 201-834-1100 |
Mailing Address - Fax: | 201-444-0350 |
Practice Address - Street 1: | 680 KINDERKAMACK RD |
Practice Address - Street 2: | 3RD FLOOR SUITE 300 |
Practice Address - City: | ORADELL |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 07649-1600 |
Practice Address - Country: | US |
Practice Address - Phone: | 201-621-0858 |
Practice Address - Fax: | 201-444-0350 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-01-18 |
Last Update Date: | 2023-09-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NJ | 207R00000X, 207RG0100X, 207V00000X, 207ZC0006X, 2085D0003X, 2085N0700X, 2085R0001X, 2085R0202X, 2085R0204X, 2085U0001X, 208600000X, 208800000X, 2088P0231X, 208C00000X | |
291U00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
No | 207ZC0006X | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology | Group - Multi-Specialty |
No | 2085D0003X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging | Group - Multi-Specialty |
No | 2085N0700X | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | Group - Multi-Specialty |
No | 2085R0001X | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | Group - Multi-Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 2085R0204X | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology | Group - Multi-Specialty |
No | 2085U0001X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 2088P0231X | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | Group - Multi-Specialty |
No | 208C00000X | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | Group - Multi-Specialty | |
No | 291U00000X | Laboratories | Clinical Medical Laboratory | Group - Multi-Specialty |