Basic Information
| Provider Information | |||||||||
| NPI: | 1487624649 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROWANSOM CARES INSTITUTE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | UMDNJ-SOM NJ CARES INSTITUTE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 71356 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191761356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666706 | ||||||||
| FaxNumber: | 8565662797 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 LAUREL RD E | ||||||||
| Address2: | UDP, SUITE 1100 | ||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565667036 | ||||||||
| FaxNumber: | 8565666108 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2006 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | WORKMAN | ||||||||
| AuthorizedOfficialFirstName: | KELI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MANAGED CARE | ||||||||
| AuthorizedOfficialTelephone: | 8565666831 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 2080C0008X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Child Abuse Pediatrics | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 3156915 | 05 | NJ | MEDICAID | 7559704 | 05 | NJ | MEDICAID |