Basic Information
| Provider Information | |||||||||
| NPI: | 1528171048 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JERSEY EMERGENCY MEDICINE SPECIALISTS, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 155 | ||||||||
| Address2: | |||||||||
| City: | CHESWICK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150240155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4128261065 | ||||||||
| FaxNumber: | 4128261491 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 ROUTE 37 W | ||||||||
| Address2: | |||||||||
| City: | TOMS RIVER | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087556423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325578000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 12/18/2007 | ||||||||
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| AuthorizedOfficialLastName: | MEREDITH | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7325578060 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5506701 | 05 | NJ | MEDICAID | CA4971 | 01 | RAILROAD MEDICARE | OTHER |