Provider Demographics
NPI:1710304563
Name:CENTRAL JERSEY MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:CENTRAL JERSEY MEDICAL CENTER, INC
Other - Org Name:SBHC MOBILE VAN
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:O'LEARY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-376-9333
Mailing Address - Street 1:PO BOX 1220
Mailing Address - Street 2:ATTN: CREDENTIALING/HR
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08862-1220
Mailing Address - Country:US
Mailing Address - Phone:732-376-6635
Mailing Address - Fax:732-324-5765
Practice Address - Street 1:275 HOBART ST
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-3396
Practice Address - Country:US
Practice Address - Phone:732-376-9333
Practice Address - Fax:732-324-5765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-18
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ063701Medicare PIN