1124118815 NPI number — TARA N CASSIDY-SMITH MD

Table of content: TARA N CASSIDY-SMITH MD (NPI 1124118815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124118815 NPI number — TARA N CASSIDY-SMITH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASSIDY-SMITH
Provider First Name:
TARA
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1124118815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 FEDERAL ST # 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08103-1088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-356-4924
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 COOPER PLZ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMDEN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08103-1461
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-342-2351
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  MA076258 , 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: 0038423 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2566254 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 39319 . This is a "UNIVERSITY HEALTH PLAN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P3344912 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 01000625100 . This is a "AMERICHOICE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1638938 . This is a "AMERIHEALTH PPO/PA BS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2313536000 . This is a "AMERIHEALTH/KEYSTONE/IBC" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3565078 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 60007325 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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