Provider Demographics
NPI:1780914879
Name:ST GEORGE CLINIC, INC.
Entity type:Organization
Organization Name:ST GEORGE CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:SALEEB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-339-4811
Mailing Address - Street 1:3455 KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-4107
Mailing Address - Country:US
Mailing Address - Phone:201-533-0003
Mailing Address - Fax:201-533-0002
Practice Address - Street 1:862 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-3054
Practice Address - Country:US
Practice Address - Phone:201-339-4811
Practice Address - Fax:201-339-4402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-12
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06522100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7831102Medicaid
NJG19319Medicare UPIN
NJ023741Medicare PIN