Provider Demographics
NPI:1427241801
Name:HACKENSACK INTERNAL MEDICINE SPECIALISTS, P.A.
Entity type:Organization
Organization Name:HACKENSACK INTERNAL MEDICINE SPECIALISTS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING EMPLOYEE / OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:RN, APN-C
Authorized Official - Phone:201-489-9119
Mailing Address - Street 1:155 POLIFLY RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-1758
Mailing Address - Country:US
Mailing Address - Phone:201-489-9119
Mailing Address - Fax:201-489-3633
Practice Address - Street 1:155 POLIFLY RD
Practice Address - Street 2:SUITE 207
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1758
Practice Address - Country:US
Practice Address - Phone:201-489-9119
Practice Address - Fax:201-489-3633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty