Basic Information
| Provider Information | |||||||||
| NPI: | 1952371494 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROWANSOM DEPT OF SURGERY | ||||||||
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| OtherOrganizationName: | UMDNJ-SOM DEPT OF SURGERY | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635 | ||||||||
| Address2: | |||||||||
| City: | BELLMAWR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080990635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666706 | ||||||||
| FaxNumber: | 8565662797 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 E LAUREL RD | ||||||||
| Address2: | UDP, SUITE 2500 | ||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565662700 | ||||||||
| FaxNumber: | 8565666873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 05/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | RIEKER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERIM CHIEF FINANCIAL OFFICIER | ||||||||
| AuthorizedOfficialTelephone: | 8567705729 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | CB0808 | 01 | NJ | RAILROAD MEDICARE | OTHER | 3155803 | 05 | NJ | MEDICAID |