Provider Demographics
NPI:1487100657
Name:NJCRI PHYSICIANS GROUP PC
Entity type:Organization
Organization Name:NJCRI PHYSICIANS GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:EKWALL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:973-483-3444
Mailing Address - Street 1:393 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-2842
Mailing Address - Country:US
Mailing Address - Phone:973-483-3444
Mailing Address - Fax:347-342-0769
Practice Address - Street 1:393 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2842
Practice Address - Country:US
Practice Address - Phone:973-483-3444
Practice Address - Fax:347-342-0769
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH JERSEY COMMUNITY RESEARCH INITIATIVE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-29
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NJ25MA05479500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty