Basic Information
| Provider Information | |||||||||
| NPI: | 1366656431 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROBERT WOOD JOHNSON KIDNEY TRANSPLANT ASSOCIATES, PA | ||||||||
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| OtherOrganizationName: | MEDEMERGE MEDICAL ASSOCIATES, PA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 EXECUTIVE DR STE 400 | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088734007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7323695994 | ||||||||
| FaxNumber: | 7323695993 | ||||||||
| Practice Location | |||||||||
| Address1: | 1005 N WASHINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | GREEN BROOK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 088122619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7329688900 | ||||||||
| FaxNumber: | 7329684609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 12/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | BERSHAD | ||||||||
| AuthorizedOfficialFirstName: | JOSHUA | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7322120051 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/30/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 057453 | 01 | NJ | MEDICARE GROUP PROVIDER NUMBER | OTHER | 8805903 | 05 | NJ | MEDICAID |