Basic Information
| Provider Information | |||||||||
| NPI: | 1881668846 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROWANSOM NEWJERSEY INSTITUTE FOR SUCCESSFUL AGING-GERIATRIC PSYCHIATRY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | UMDNJ-SOM NEWJERSEY INSTITUTE FORSUCCESSFUL AGING-GERIATRIC PSYCHIATRY | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 635 | ||||||||
| Address2: | |||||||||
| City: | BELLMAWR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080990635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666706 | ||||||||
| FaxNumber: | 8565662797 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 EAST LAUREL ROAD | ||||||||
| Address2: | UDP, SUITE 1800 | ||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666843 | ||||||||
| FaxNumber: | 8565666419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2006 | ||||||||
| LastUpdateDate: | 05/15/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | RIEKER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CHIEF FINANCIAL OFFICIER | ||||||||
| AuthorizedOfficialTelephone: | 8567705729 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 103G00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | CK3636 | 01 | NJ | RAILROAD MEDICARE | OTHER | 7851006 | 05 | NJ | MEDICAID |