Provider Demographics
NPI:1316317787
Name:SOVEREIGN MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:SOVEREIGN MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAJJAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-855-8302
Mailing Address - Street 1:85 HARRISTOWN RD
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-3329
Mailing Address - Country:US
Mailing Address - Phone:201-855-8301
Mailing Address - Fax:
Practice Address - Street 1:265 E 33RD ST
Practice Address - Street 2:
Practice Address - City:PATERSON
Practice Address - State:NJ
Practice Address - Zip Code:07504-1668
Practice Address - Country:US
Practice Address - Phone:973-684-1011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6693740002Medicare NSC