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State of New Jersey Medicaid Fraud Division Provider Exclusion Report

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State of New Jersey Medicaid Fraud Division Provider Exclusion Report State of New Jersey 1 Medicaid Fraud Division Provider Exclusion Report Updated on: 8/23/2021 **ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES** PROVIDER NAME TITLE DATE OF NPI NUMBER STREET CITY STA ZIP ACTION EFFECTIVE EXPIRATION BIRTH TE DATE DATE 2258 PHARMACY, INC. 2258 THIRD AVENUE NEW YORK NY 10035 SUSPENSION 7/20/2003 6522 VENTNOR AVE. 6522 VENTNOR AVENUE VENTNOR NJ 08406 DISQUALIFICATION PHARMACY, INC. ABARCA, CHERYL R. LPN 8/15/1962 528 3RD STREET NEWARK NJ 07107 SUSPENSION 6/20/2005 ABASHKIN, ROMAN CHHA 12/21/1981 72 RIDGEVIEW TERRACE WAYNE NJ 07470 DISQUALIFICATION 5/29/2015 ABASHKIN, ROMAN CHHA 12/21/1981 72 RIDGEVIEW TERRACE WAYNE NJ 07470 DISQUALIFICATION 6/3/2016 ABBASSI, JADAN MD 9/19/1944 1194807255 1618 MAIN AVENUE CLIFTON NJ 07011 DISQUALIFICATION 11/21/2016 PERMANENT ABBASSI, JADAN MD 9/19/1944 1194807255 115 NELLIS DRIVE WAYNE NJ 07470 DISQUALIFICATION 6/20/2018 PERMANENT ABDALLA, IZZELDIN 4/5/1967 1116 ANNE STREET ELIZABETH NJ 07201 DISQUALIFICATION 11/10/1999 ABDELGANI, AMIR ALLENWOOD USP WHITE DEER PA 17887 DISQUALIFICATION 11/26/2001 ABDELGANI, FADIL TERRE HAUTE USP TERRE HAUTE IN 47808 DISQUALIFICATION 11/26/2001 ABDELHAMID, MANAL RPH 5/28/1969 7100 BOULEVARD EAST, 11G GUTTENBERG NJ 07093 DEBARMENT 3/15/2001 ABDOLLAHI, MITRA DMD 8/31/1966 1033329230 646 N. SARATOGA DRIVE MOORESTOWN NJ 08057 DISQUALIFICATION 11/5/2007 7/19/2019 ABERBACH, STEVEN RPH 8/5/1944 23 STONEGATE DRIVE WATCHUNG NJ 07069 DEBARMENT 12/19/2003 ABOOD, ABDOLMAID S. 1/20/1966 64 BEVAN STREET JERSEY CITY NJ 07306 SUSPENSION 5/7/1997 ABOODS MEDICAL LIVERY 64 BEVAN STREET JERSEY CITY NJ 07306 DISQUALIFICATION 5/22/1994 ABOUELHODA, AHMED RPH 3/23/1974 33-17 60TH STREET, APT. 1 WOODSIDE NY 11377 SUSPENSION 9/20/2005 ABRAHAMSEN, SVEND DPM 9/17/1944 101 CHESTNUT RIDGE ROAD SADDLE RIVER NJ 07458 DISQUALIFICATION 4/20/1994 ABRAMS, DE'NYSHIA CHHA 11/16/1993 410 3RD AVENUE, APT. 1A ASBURY PARK NJ 07712 DISQUALIFICATION 7/16/2018 ABRAMS, IRVING RPH 12/23/1949 5 LORENE WAY MORGANVILLE NJ 07551 SUSPENSION 4/27/2000 ABREU MARTINEZ, CHHA 12/14/1989 14 EAST RUSSELL STREET CLIFTON NJ 07011 DEBARMENT 10/31/2017 ABUSEF, ELSAYED K. SUTEX 814 74TH STREET NORTH BERGEN NJ 07047 DISQUALIFICATION 5/20/1999 MED. TRANSP ORT AC HOME NURSING 1235230665 2921 YOUNGSTOWN ROAD WARREN OH 44484 DISQUALIFICATION 11/20/2015 ACKLEY, GEORGE PSYCH 5/13/1944 1457535833 202 LENOX AVENUE CAPE MAY NJ 08204 DEBARMENT 7/21/2015 ACOSTA, LEILANI CHHA 4/14/1977 458 STEVENSON PLACE, 1ST PERTH AMBOY NJ 08861 DISQUALIFICATION 5/9/2019 FL ACOSTA, PEDRO E. 1/23/1945 5815 43RD AVENUE WOODSIDE NY 11377 SUSPENSION 4/13/2008 For verifications please contact: [email protected] Send an email to [email protected] to receive this report in .xls format State of New Jersey 2 Medicaid Fraud Division Provider Exclusion Report Updated on: 8/23/2021 **ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES** PROVIDER NAME TITLE DATE OF NPI NUMBER STREET CITY STA ZIP ACTION EFFECTIVE EXPIRATION BIRTH TE DATE DATE ACOSTA, PEDRO E. 1/23/1945 5815 43RD AVENUE WOODSIDE NY 11377 DISQUALIFICATION 5/2/2008 ACOSTA, PEDRO E. 1/23/1945 5815 43RD AVENUE, 1ST WOODSIDE NY 11377 DISQUALIFICATION 9/16/2011 FLOOR ACOSTA, WILLIAM R. MD 8/24/1949 47 OSBORNE STREET JOHNSTOWN PA 15905 DISQUALIFICATION 11/20/2015 ACQUAH, ROSE AKA CHHA 10/1/1984 5507 WARNER VIEW LANE WESTVILLE OH 43081 DEBARMENT 7/13/2018 MANFORD, ROSE ACQUAIRE, FLORENCE 7/4/1940 EMCF PO BOX 08809 CLINTON NJ 08809 SUSPENSION 4/20/2006 ACQUAYE, EDWARD 2/9/1950 10 BERWICK CIRCLE NORTH BRUNSWICK NJ 08902 SUSPENSION 4/19/2007 ACZON, FERDINAND B. MD 11/29/1948 1255422135 204 SUMMIT ROAD MOUNT LAUREL NJ 08054 DISQUALIFICATION 9/20/2011 11/23/2016 ADADEVOH, LOVESDALE CHHA 12/10/1977 1 SKYTOP GARDENS, APT. 19 PARLIN NJ 08859 DISQUALIFICATION 7/16/2019 AKA HAMENOO, LOVESDALE ADAIR, LISA AKA LPN 4/20/1961 206 LAKEHURST AVENUE, NATIONAL PARK NJ 08063 SUSPENSION 9/19/2002 TARASEVICH, LISA APT. B ADAMS, AMELIA CHHA 9/26/1994 132 OAKMONT ROAD CLEMENTON NJ 08021 DISQUALIFICATION 1/31/2017 ADAMS, ANTOINETTE CHHA 12/29/1976 1604 SEWALL AVENUE ASBURY PARK NJ 07712 DISQUALIFICATION 1/31/2017 ADAMS, JAIME L. CHHA 4/15/1976 911 W. HAND AVENUE CAPE MAY COURT NJ 08210 SUSPENSION 6/19/2003 HOUSE ADAMSHICK, WILLIAM RPH 10/9/1960 1871842575 2516 HURRY ROAD FORKED RIVER NJ 08731 SUSPENSION 7/14/2005 3/21/2012 ADDIS, DAVID J. MD 8/10/1944 1770656068 334 FARNSWORTH AVENUE BORDENTOWN NJ 08505 DEBARMENT 1/20/2015 PERMANENT ADES, ALBERT MD 1/11/1955 1912069394 3 MARKHAM CIRCLE ENGLEWOOD NJ 07631 DEBARMENT 5/16/2016 ADES, ALBERT MD 1/11/1955 1912069394 PO BOX 779800 MIAMI FL 33177 DISQUALIFICATION 12/12/2016 ADES, ALBERT (DR.'S 1447560867 129 MADISON AVENUE CRESSKILL NJ 07626 DISQUALIFICATION 6/16/2017 OFFICE) ADISSON, LECLERC MD 8/14/1946 1482 SW 150TH TERRACE SUNRISE FL 33326 DISQUALIFICATION 7/20/2007 PERMANENT ADISSON, LUNIC CHHA 11/29/1971 14 WALTER PLACE #1 IRVINGTON NJ 07111 DISQUALIFICATION 3/14/2008 ADOLPHE, NAOMIE CHHA 8/24/1982 410 FISHER AVENUE NEPTUNE NJ 07753 DISQUALIFICATION 2/20/2017 ADU-BOAHENE, CHHA 2/19/1975 3 AUGUSTA DRIVE LITTLE EGG HARBOR NJ 08087 DISQUALIFICATION 1/23/2018 KWABENA AFRIYIE, BRIGHT CHHA 6/20/1994 317 W. RUNYON STREET, 3L NEWARK NJ 07108 DISQUALIFICATION 1/23/2018 AGARWAL, SHASHI K. MD 6/15/1952 1558416099 198 CENTRAL AVENUE, 1ST EAST ORANGE NJ 07018 SUSPENSION 10/22/2012 FL For verifications please contact: [email protected] Send an email to [email protected] to receive this report in .xls format State of New Jersey 3 Medicaid Fraud Division Provider Exclusion Report Updated on: 8/23/2021 **ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES** PROVIDER NAME TITLE DATE OF NPI NUMBER STREET CITY STA ZIP ACTION EFFECTIVE EXPIRATION BIRTH TE DATE DATE AGARWAL, SHASHI K. MD 6/15/1952 1558416099 FCI SCHUYLKILL, PO BOX 759 MINERSVILLE PA 17954 DEBARMENT 2/28/2014 AGRAWAL, PANKAJ MD 9/16/1949 1962661215 3 E. MEADOWBROOK CIRCLE SICKLERVILLE NJ 08081 DISQUALIFICATION 3/11/2006 AGRESTA JR., RUDOLPH G. MD 8/18/1954 PO BOX 7450 TRENTON NJ 08628 SUSPENSION 2/19/2004 AGRESTI, JAMES MD 2/18/1970 1255389813/ 292 FAIRMONT ROAD LONG VALLEY NJ 07853 DEBARMENT 10/5/2020 1477874352 AGRESTI, ROBERT MD 4/11/1957 1619155710 15 BARBERRY WAY ESSEX FALLS NJ 07021 DISQUALIFICATION 6/26/2018 AGUH, CHIKEZIE MD 6/23/1956 1407876261/ 18 MULBERRY COURT BELLE MEAD NJ 08502 DISQUALIFICATION 2/11/2021 1619997483 AGUIAR, SANDRA 2/3/1967 605 KNICKERBOCKER ROAD TENAFLY NJ 07670 DISQUALIFICATION 6/18/2009 AGUILAR, RUBEN RPH 9/21/1962 16 GOLDENROD DRIVE BELLE MEAD NJ 08502 SUSPENSION 7/20/2010 AGUIRRE-MEDRANO, 10/24/1915 40 FERRY STREET NEWARK NJ 07105 DEBARMENT 7/12/1999 CANDIDA AGYEMANG, JOHN RPH 2/18/1969 1487934626 153 BLUE MEADOW LANE SICKLERVILLE NJ 08081 DISQUALIFICATION 12/28/2016 9/22/2020 AGYEMANG, KWADWO RPH 3/8/1958 1154713394 94 MARKET STREET NEWARK NJ 07102 DEBARMENT 8/25/2003 6/3/2015 AHLAWAT, RANVIR MD 7/21/1964 1447204615 2204 ARVELL STREET TOMS RIVER NJ 08755 DEBARMENT 12/19/2016 AHMAD, ABADULLAH 4/3/1984 280 LOUIS MARIN JERSEY CITY NJ 07302 SUSPENSION 2/19/2009 BOULEVARD #15 AHMAD, FAROOQ RPH 10/1/1943 1659605590 300 EAST HALSEY ROAD PARSIPPANY NJ 07054 SUSPENSION 11/8/1994 AHMAD, NAEEM S 682 BERGEN AVENUE JERSEY CITY NJ 07306 DISQUALIFICATION 9/15/1983 AHMAD, NAVEED MD 1/3/1950 1669412946 48 SUYDAM ROAD SOMERSET NJ 08873 DISQUALIFICATION 9/29/2016 PERMANENT AHMAD, NAVEED MD 1/3/1950 1669412946 48 SUYDAM ROAD SOMERSET NJ 08873 DISQUALIFICATION 12/20/2016 PERMANENT AHMED, AMIR E. 1/1/1962 7-11 TONNELLE AVENUE- JERSEY CITY NJ 07306 SUSPENSION 5/30/1997 2MN AHMED, KHALID H. 2/6/1963 PO BOX 930 NEW YORK NY 10013 DISQUALIFICATION 3/26/1994 AHMED, MOHAMED G. PHARM 7/14/1989 5 WESTOVER TERRACE WEST ORANGE NJ 07052 DISQUALIFICATION 8/20/2010 TECH AIRD, EILEEN, B. 6/28/1950 295 GRANDVIEW CIRCLE RIDGEWOOD NJ 07450 SUSPENSION 4/20/2003 AKANDE, EZEKIEL MD 1/15/1959 1003859885 300 HAIL KNOB ROAD, SOMERSET KY 42503 DISQUALIFICATION 9/20/2017 #290828 For verifications please contact: [email protected] Send an email to [email protected] to receive this report in .xls format State of New Jersey 4 Medicaid Fraud Division Provider Exclusion Report Updated on: 8/23/2021 **ADDITIONAL NPI NUMBERS MAY BE ASSOCIATED WITH THE LISTED INDIVIDUALS/ENTITIES** PROVIDER NAME TITLE DATE OF NPI NUMBER STREET CITY STA ZIP ACTION EFFECTIVE EXPIRATION BIRTH TE DATE DATE AKHMEDOV, KHUSEN 8/1/1990 SCI GRATERFORD, ME9849, GRATERFORD PA 19426 DISQUALIFICATION 11/20/2015 PO BOX 244 AKHTAR, NADEEM RPH 12/16/1959 1063695963 15 GRIST MILL LANE UPPER SADDLE RIVER NJ 07458 DEBARMENT 1/20/2012 AKHTAR, NADEEM RPH 12/16/1959 1063695963 15 GRIST MILL LANE UPPER SADDLE RIVER NJ 07458 DISQUALIFICATION 9/20/2012 AKINBILE, MORUFU O. RN 5/1/1966 419 E. MOOREHAVEN DRIVE CARSON CA 90746 DISQUALIFICATION 8/20/2010 AL SALIHI, FAROUK MD 7/1/1934 1720158025 1810 JOHN F. KENNEDY JERSEY CITY NJ 07305 SUSPENSION 5/1/2011 BOULEVARD AL SALIHI, FAROUK MD 7/1/1934 1720158025 1810 JOHN F. KENNEDY JERSEY CITY NJ 07305 DEBARMENT 1/9/2015 BOULEVARD ALAMEEN, ALWALEED TEMPT 5/16/1968 238 MAIN STREET HACKENSACK NJ 07601 SUSPENSION 7/18/1995 TRANS ALAN, DAVID OD 7/26/1946 1225012073 203 NORTH REDWOOD MASONTOWN PA 15461 DISQUALIFICATION 11/20/2015 STREET ALBERS, HENRY J.
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