Basic Information
| Provider Information | |||||||||
| NPI: | 1619126984 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH JERSEY GASTROENTEROLOGY CONSULTANTS PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 183 | ||||||||
| Address2: | |||||||||
| City: | BRIDGETON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083020137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564519395 | ||||||||
| FaxNumber: | 8564518615 | ||||||||
| Practice Location | |||||||||
| Address1: | 1103 W SHERMAN AVE | ||||||||
| Address2: | BLDG 2 UNIT A | ||||||||
| City: | VINELAND | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083606915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566929900 | ||||||||
| FaxNumber: | 8566929911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2008 | ||||||||
| LastUpdateDate: | 09/15/2011 | ||||||||
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| AuthorizedOfficialLastName: | HAMMOD | ||||||||
| AuthorizedOfficialFirstName: | RIYADH | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8564519395 | ||||||||
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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 | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 8752401 | 05 | NJ | MEDICAID |