Provider Demographics
NPI:1649904772
Name:HACKENSACK MEDICAL GROUP LLC
Entity type:Organization
Organization Name:HACKENSACK MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LIONEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ANICETTE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:973-234-0779
Mailing Address - Street 1:483 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07079-2642
Mailing Address - Country:US
Mailing Address - Phone:973-234-0779
Mailing Address - Fax:973-453-8059
Practice Address - Street 1:341 ESSEX ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-2048
Practice Address - Country:US
Practice Address - Phone:973-234-0779
Practice Address - Fax:973-453-8059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No251J00000XAgenciesNursing CareGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)