Basic Information
| Provider Information | |||||||||
| NPI: | 1043857436 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROSPERO MEDICAL SERVICES NEW JERSEY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 S B B KING BLVD | ||||||||
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| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381032626 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014227644 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 GATEWAY CTR STE 2600 | ||||||||
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| City: | NEWARK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 071025323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669490108 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2019 | ||||||||
| LastUpdateDate: | 12/27/2021 | ||||||||
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| AuthorizedOfficialLastName: | MANN | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9014227608 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 12/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QH0002X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
No ID Information.