Basic Information
| Provider Information | |||||||||
| NPI: | 1922090786 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH JERSEY HEART GROUP, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 CHAPEL AVE W | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080021592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564828900 | ||||||||
| FaxNumber: | 8564827170 | ||||||||
| Practice Location | |||||||||
| Address1: | 3001 CHAPEL AVE W | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080021592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564828900 | ||||||||
| FaxNumber: | 8564827170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 10/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | BAGARIA | ||||||||
| AuthorizedOfficialFirstName: | SURENDRA | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CO-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8565890300 | ||||||||
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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 | 207RC0000X | MA46206 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 569007 | 01 | NJ | AETNA | OTHER | 7042507 | 05 | NJ | MEDICAID |