Provider Demographics
NPI:1295983484
Name:MONTCLAIR HOSPITAL LLC
Entity type:Organization
Organization Name:MONTCLAIR HOSPITAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-465-9222
Mailing Address - Street 1:799 BLOOMFIELD AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:799 BLOOMFIELD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-1367
Practice Address - Country:US
Practice Address - Phone:973-746-7050
Practice Address - Fax:973-857-2831
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MONTCLAIR HOSPITAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-03
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ10766261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ10766OtherSTATE LICENSE NUMBER
NJ10766OtherSTATE LICENSE NUMBER