Provider Demographics
NPI:1427092675
Name:PERTH AMBOY HEALTH CARE L.L.C.
Entity type:Organization
Organization Name:PERTH AMBOY HEALTH CARE L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PAULETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-442-5444
Mailing Address - Street 1:607 AMBOY AVENUE
Mailing Address - Street 2:
Mailing Address - City:PERTH AMBOY
Mailing Address - State:NJ
Mailing Address - Zip Code:08861-2595
Mailing Address - Country:US
Mailing Address - Phone:732-442-5444
Mailing Address - Fax:732-442-2626
Practice Address - Street 1:607 AMBOY AVENUE
Practice Address - Street 2:
Practice Address - City:PERTH AMBOY
Practice Address - State:NJ
Practice Address - Zip Code:08861-2595
Practice Address - Country:US
Practice Address - Phone:732-442-5444
Practice Address - Fax:732-442-2626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-16
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22620261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8180202Medicaid
NJC11707Medicare UPIN
NJ8180202Medicaid