Provider Demographics
NPI:1053367334
Name:MONTCLAIR BREAST CENTER PC
Entity type:Organization
Organization Name:MONTCLAIR BREAST CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:862-392-0022
Mailing Address - Street 1:37 NO FULLERTON AVENUE
Mailing Address - Street 2:MONTCLAIR BREAST CENTER PC
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3426
Mailing Address - Country:US
Mailing Address - Phone:973-509-1818
Mailing Address - Fax:973-509-0708
Practice Address - Street 1:37 NO FULLERTON AVENUE
Practice Address - Street 2:MONTCLAIR BREAST CENTER PC
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3426
Practice Address - Country:US
Practice Address - Phone:973-509-1818
Practice Address - Fax:973-509-0708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-26
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2085R0202X, 2085U0001X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ23317OtherFDA MRI
NJ126219OtherFDA RADIOLOGY
NJ23317OtherFDA MRI