1912316639 NPI number — GENUINE ME OF SOUTH JERSEY INC

Table of content: (NPI 1912316639)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912316639 NPI number — GENUINE ME OF SOUTH JERSEY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GENUINE ME OF SOUTH JERSEY INC
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:
1912316639
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3 CRANBURY HILL CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT LAUREL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08054-4849
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
609-828-0097
Provider Business Mailing Address Fax Number:
856-802-0885

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 CHURCH RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARLTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
609-828-0097
Provider Business Practice Location Address Fax Number:
856-802-0885
Provider Enumeration Date:
08/06/2014

Additional Information

Authorized Official

Authorized Official Last Name:
FADOOL
Authorized Official First Name:
JOANNE
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
609-828-0097

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  44SC05576600 , 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: 0450088977 . This is a "NEW JERSERY CERTIFICATE OF INC (PROFIT)" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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