Provider Demographics
NPI:1780884031
Name:CATHEDRAL PHYSICIAN GROUP, PC
Entity type:Organization
Organization Name:CATHEDRAL PHYSICIAN GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:
Authorized Official - Last Name:BENDEZU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-877-5188
Mailing Address - Street 1:111 CENTRAL AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-1909
Mailing Address - Country:US
Mailing Address - Phone:973-877-5000
Mailing Address - Fax:
Practice Address - Street 1:1160 RAYMOND BLVD
Practice Address - Street 2:8TH FLOOR - PHYSICIAN SERVICES
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-4168
Practice Address - Country:US
Practice Address - Phone:973-491-2958
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SAINT MICHAELS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-24
Last Update Date:2007-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJPENDINGMedicaid
NJPENDINGMedicaid