1376575993 NPI number — JERSEY SHORE PODIATRIC ASSOCIATES

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 1376575993 NPI number — JERSEY SHORE PODIATRIC ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JERSEY SHORE PODIATRIC ASSOCIATES
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:
1376575993
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 825159
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19182-5159
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-974-8200
Provider Business Mailing Address Fax Number:
732-974-0190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2130 HIGHWAY 35
Provider Second Line Business Practice Location Address:
BLDG C STE 312
Provider Business Practice Location Address City Name:
SEA GIRT
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08750-1010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-974-8200
Provider Business Practice Location Address Fax Number:
732-974-0190
Provider Enumeration Date:
07/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MIRKIN
Authorized Official First Name:
GENE
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
410-266-7575

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X , with the licence number: MD2271 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1130013 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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