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
StateLicense IDTaxonomies
NJ207R00000X, 207RG0100X, 207V00000X, 207ZC0006X, 2085D0003X, 2085N0700X, 2085R0001X, 2085R0202X, 2085R0204X, 2085U0001X, 208600000X, 208800000X, 2088P0231X, 208C00000X
291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical PathologyGroup - Multi-Specialty
No2085D0003XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic NeuroimagingGroup - Multi-Specialty
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiologyGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty