Provider Demographics
NPI:1386772226
Name:THE CONNIE DWYER BREAST CENTER
Entity type:Organization
Organization Name:THE CONNIE DWYER BREAST CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING REPRESENTATIVE
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-996-4053
Mailing Address - Street 1:PO BOX 2047
Mailing Address - Street 2:
Mailing Address - City:SOUTH HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07606-0647
Mailing Address - Country:US
Mailing Address - Phone:201-968-9456
Mailing Address - Fax:201-336-8198
Practice Address - Street 1:111 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1909
Practice Address - Country:US
Practice Address - Phone:973-877-5189
Practice Address - Fax:973-877-5205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA027844002085R0202X
NJ25MA07666200208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty