Basic Information
| Provider Information | |||||||||
| NPI: | 1982641775 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KERNIZAN | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | E. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 307 S EVERGREEN AVE | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080962739 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566864300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 TOWNSEND AVE | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080099011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563223260 | ||||||||
| FaxNumber: | 8563223061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 05/15/2012 | ||||||||
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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 | 207P00000X | MA46639 | NJ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD040706E | PA | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0944602 | 05 | NJ | MEDICAID | 599214 | 01 | PA | HIGHMARK BLUE SHIELD | OTHER | 0421620000 | 01 | PA | KEYSTONE IBC | OTHER | 0011968430002 | 05 | PA | MEDICAID | 1090254 | 01 | PA | KEYSTONE MERCY | OTHER | 45279 | 01 | PA | AETNA CONTRACTED | OTHER |