Provider Demographics
NPI:1891706842
Name:HILLSIDE FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:HILLSIDE FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:MATKIWSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:908-353-7949
Mailing Address - Street 1:100 HOLLYWOOD AVE
Mailing Address - Street 2:HILLSIDE FAMILY PRACTICE
Mailing Address - City:HILLSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:07205-2409
Mailing Address - Country:US
Mailing Address - Phone:908-353-7949
Mailing Address - Fax:908-353-8374
Practice Address - Street 1:100 HOLLYWOOD AVE
Practice Address - Street 2:HILLSIDE FAMILY PRACTICE
Practice Address - City:HILLSIDE
Practice Address - State:NJ
Practice Address - Zip Code:07205-2409
Practice Address - Country:US
Practice Address - Phone:908-353-7949
Practice Address - Fax:908-353-8374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB02410900207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0048071Medicaid
NJ0048071Medicaid