Provider Demographics
NPI:1831722586
Name:PRIME HEALTHCARE SERVICES - ST. MARY'S PASSAIC LLC
Entity type:Organization
Organization Name:PRIME HEALTHCARE SERVICES - ST. MARY'S PASSAIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING ASSOCIATE GENERAL COUNSEL
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:DOAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-259-4706
Mailing Address - Street 1:350 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-2840
Mailing Address - Country:US
Mailing Address - Phone:973-365-4300
Mailing Address - Fax:
Practice Address - Street 1:350 BOULEVARD
Practice Address - Street 2:
Practice Address - City:PASSAIC
Practice Address - State:NJ
Practice Address - Zip Code:07055-2840
Practice Address - Country:US
Practice Address - Phone:973-365-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-20
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0737721Medicaid