Basic Information
| Provider Information | |||||||||
| NPI: | 1205023132 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERIDIAN HEALTH SYSTEMS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | JERSEY SHORE UNVERSITY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1945 CORLIES AVE | ||||||||
| Address2: | |||||||||
| City: | NEPTUNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077534859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327762325 | ||||||||
| FaxNumber: | 7327762329 | ||||||||
| Practice Location | |||||||||
| Address1: | 1945 CORLIES AVE | ||||||||
| Address2: | |||||||||
| City: | NEPTUNE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077534859 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327762325 | ||||||||
| FaxNumber: | 7327762329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2007 | ||||||||
| LastUpdateDate: | 09/25/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GIBILISCO-ZYKORIE | ||||||||
| AuthorizedOfficialFirstName: | DOMINIC | ||||||||
| AuthorizedOfficialMiddleName: | PETER | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSE | ||||||||
| AuthorizedOfficialTelephone: | 7327762325 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283Q00000X | 26NR11987500 | NJ | Y | Hospitals | Psychiatric Hospital |
No ID Information.