1982641775 NPI number — JOSEPH E. KERNIZAN MD

Table of content: JOSEPH E. KERNIZAN MD (NPI 1982641775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982641775 NPI number — JOSEPH E. KERNIZAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KERNIZAN
Provider First Name:
JOSEPH
Provider Middle Name:
E.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1982641775
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
307 S EVERGREEN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08096-2739
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-686-4300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 TOWNSEND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERLIN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08009-9011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-322-3260
Provider Business Practice Location Address Fax Number:
856-322-3061
Provider Enumeration Date:
06/01/2006

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:  MA46639 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207P00000X , with the licence number: MD040706E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0944602 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 599214 . This is a "HIGHMARK BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0421620000 . This is a "KEYSTONE IBC" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0011968430002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1090254 . This is a "KEYSTONE MERCY" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 45279 . This is a "AETNA CONTRACTED" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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