Basic Information
| Provider Information | |||||||||
| NPI: | 1902980352 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIRSEN | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 COOPER PLZ | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563422445 | ||||||||
| FaxNumber: | 8569640504 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 COOPER PLZ | ||||||||
| Address2: | SUITE 215 (NEUROLOGY) | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563422445 | ||||||||
| FaxNumber: | 8569640504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 04/25/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MA54529 | NJ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 010003879 | 01 | AMERICHOICE | OTHER | P440700 | 01 | OXFORD | OTHER | 7808502 | 01 | CIGNA | OTHER | 3K6143 | 01 | HEALTHNET | OTHER | 1024720 | 01 | HORIZON NJ HEALTH | OTHER | 1243169 | 01 | UNITED HEALTHCARE | OTHER | 567399 | 01 | AMERIHEALTH PPO | OTHER | 0388541000 | 01 | AMERIHEALTH, KEYSTONE, IBC | OTHER | 0518267 | 01 | AETNA | OTHER | 0651800 | 05 | NJ | MEDICAID | 110084266 | 01 | RR MEDICARE | OTHER | 13517 | 01 | UNIVERSITY HEALTH PLAN | OTHER |