Provider Demographics
NPI:1750402202
Name:ST. MARY'S HOSPITAL
Entity type:Organization
Organization Name:ST. MARY'S HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PATIENT ACCOUNTS
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:BODNAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-365-3012
Mailing Address - Street 1:350 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-2840
Mailing Address - Country:US
Mailing Address - Phone:973-365-3012
Mailing Address - Fax:
Practice Address - Street 1:33 MINERAL SPRING AVE
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-2512
Practice Address - Country:US
Practice Address - Phone:973-470-3181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ30407R05Y107322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8368902Medicaid