1578563052 NPI number — SALEM CLINIC CORP

Table of content: MARY EILEEN TREMBLAY P.T. (NPI 1669599494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578563052 NPI number — SALEM CLINIC CORP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALEM CLINIC CORP
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:
1578563052
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4 BYPASS ROAD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08079
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-935-3582
Provider Business Mailing Address Fax Number:
856-935-4382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4 BYPASS ROAD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08079
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-935-3582
Provider Business Practice Location Address Fax Number:
856-935-4382
Provider Enumeration Date:
07/27/2005

Additional Information

Authorized Official

Authorized Official Last Name:
NEWSOME
Authorized Official First Name:
GARY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
616-373-9600

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , 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: 8996105 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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