1023041480 NPI number — SOUTHERN OCEAN SPECIALTY PHYSICIANS, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023041480 NPI number — SOUTHERN OCEAN SPECIALTY PHYSICIANS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN OCEAN SPECIALTY PHYSICIANS, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023041480
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1364 ROUTE 72 W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANAHAWKIN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08050-2485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-971-7986
Provider Business Mailing Address Fax Number:
609-597-4557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 ROUTE 72 W
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
MANAHAWKIN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08050-2468
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-978-3359
Provider Business Practice Location Address Fax Number:
609-978-3060
Provider Enumeration Date:
07/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NIEWIADOMSKI
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
609-978-8900

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RH0003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0069329 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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