1356514335 NPI number — SOUTH JERSEY GASTROENTEROLOGY PA

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 1356514335 NPI number — SOUTH JERSEY GASTROENTEROLOGY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTH JERSEY GASTROENTEROLOGY PA
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:
6
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:
1356514335
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
406 LIPPINCOTT DR
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
MARLTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08053-4168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-983-1900
Provider Business Mailing Address Fax Number:
856-983-1914

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
93 COOPER RD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
VOORHEES
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08043-4910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-770-1920
Provider Business Practice Location Address Fax Number:
856-770-1925
Provider Enumeration Date:
04/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
LIAKOS
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
856-983-1900

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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