Provider Demographics
NPI:1922388008
Name:BRAIN INSTITUTE OF NORTHERN NEW JERSEY PA
Entity type:Organization
Organization Name:BRAIN INSTITUTE OF NORTHERN NEW JERSEY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAJENKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:646-712-1635
Mailing Address - Street 1:725 RIVER RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:EDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:07020-1171
Mailing Address - Country:US
Mailing Address - Phone:646-712-1635
Mailing Address - Fax:866-267-8173
Practice Address - Street 1:8 S MORRIS ST
Practice Address - Street 2:SUITE 302
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801-4649
Practice Address - Country:US
Practice Address - Phone:646-712-1635
Practice Address - Fax:866-267-8173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08061700261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty