1417907676 NPI number — JERROLD FRIEDMAN, M.D.

Table of content: (NPI 1417907676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417907676 NPI number — JERROLD FRIEDMAN, M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JERROLD FRIEDMAN, M.D.
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:
1417907676
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
08/19/2008
NPI Reactivation Date:
11/05/2009

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1272
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARLTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08053-6272
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-755-1616
Provider Business Mailing Address Fax Number:
856-755-0098

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3001 E EVESHAM RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VOORHEES
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08043-9547
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-751-1600
Provider Business Practice Location Address Fax Number:
856-751-1548
Provider Enumeration Date:
05/10/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
FRIEDMAN
Authorized Official First Name:
JERROLD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
856-755-1616

Provider Taxonomy Codes

  • Taxonomy code: 208100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0343567000 . This is a "AMERIHEALTH HMO/PPO" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 568292 . This is a "AMERIHEALTH ADMINISTRATOR" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2672520 . This is a "AETNA HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 069469768 . This is a "TAX ID" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5365751 . This is a "AETNA PPO" identifier . This identifiers is of the category "OTHER".