1700821352 NPI number — SOUTH JERSEY ANESTHESIA AND PAIN PHYSICIANS PC

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 1700821352 NPI number — SOUTH JERSEY ANESTHESIA AND PAIN PHYSICIANS PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH JERSEY ANESTHESIA AND PAIN PHYSICIANS PC
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:
1700821352
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 95000 LB# 7785
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:
19195-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-841-3049
Provider Business Mailing Address Fax Number:
856-686-5319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
509 N BROAD ST
Provider Second Line Business Practice Location Address:
UNDERWOOD MEMORIAL HOSPITAL
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08096-1617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-845-0100
Provider Business Practice Location Address Fax Number:
856-686-5319
Provider Enumeration Date:
06/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DRAGON
Authorized Official First Name:
GLENN
Authorized Official Middle Name:
Authorized Official Title or Position:
HEAD OF GROUP
Authorized Official Telephone Number:
856-508-1260

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , 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: 8065900 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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