Basic Information
| Provider Information | |||||||||
| NPI: | 1285789909 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | REHABILITATION PHYSICIANS OF SOUTH JERSEY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1237 W SHERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | VINELAND | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083606920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566967100 | ||||||||
| FaxNumber: | 8566963065 | ||||||||
| Practice Location | |||||||||
| Address1: | 1237 W SHERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | VINELAND | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083606920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566967100 | ||||||||
| FaxNumber: | 8566963065 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BONNER | ||||||||
| AuthorizedOfficialFirstName: | FRANCIS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | SOLE MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8568962008 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 208100000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2084N0400X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 0094072 | 05 | NJ | MEDICAID |