Provider Demographics
NPI:1720032964
Name:CATHEDRAL PHYSICIAN SERVICES, P.C.
Entity Type:Organization
Organization Name:CATHEDRAL PHYSICIAN SERVICES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-877-5300
Mailing Address - Street 1:111 CENTRAL AVE
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-1909
Mailing Address - Country:US
Mailing Address - Phone:973-877-5300
Mailing Address - Fax:973-877-2621
Practice Address - Street 1:111 CENTRAL AVE
Practice Address - Street 2:3RD FLOOR
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1909
Practice Address - Country:US
Practice Address - Phone:973-877-5300
Practice Address - Fax:973-877-2621
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ095349Medicare ID - Type Unspecified