Provider Demographics
NPI:1356514335
Name:SOUTH JERSEY GASTROENTEROLOGY PA
Entity type:Organization
Organization Name:SOUTH JERSEY GASTROENTEROLOGY PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LIAKOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-983-1900
Mailing Address - Street 1:406 LIPPINCOTT DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4168
Mailing Address - Country:US
Mailing Address - Phone:856-983-1900
Mailing Address - Fax:856-983-1914
Practice Address - Street 1:93 COOPER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4910
Practice Address - Country:US
Practice Address - Phone:856-770-1920
Practice Address - Fax:856-770-1925
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH JERSEY GASTROENTEROLOGY PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-10
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ526660Medicare PIN