Provider Demographics
NPI:1851757645
Name:CITY OF NEWARK
Entity Type:Organization
Organization Name:CITY OF NEWARK
Other - Org Name:NEWARK DEPT OF HLTH & COMM WELLNESS-DENTAL MARY ELIZA MAHONEY HLTH CTR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL OPERATIONS OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:OLUYINKA
Authorized Official - Middle Name:
Authorized Official - Last Name:FADAHUNSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-733-7558
Mailing Address - Street 1:110 WILLIAM ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-1304
Mailing Address - Country:US
Mailing Address - Phone:973-733-7558
Mailing Address - Fax:973-733-4328
Practice Address - Street 1:110 WILLIAM ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1304
Practice Address - Country:US
Practice Address - Phone:973-733-7558
Practice Address - Fax:973-733-4328
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-08
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ7082261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0034002Medicaid
NJ0034002Medicaid