Provider Demographics
NPI:1538336359
Name:SR CAMPUS PRIMARY CARE PHYSICIANS PC
Entity type:Organization
Organization Name:SR CAMPUS PRIMARY CARE PHYSICIANS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:NARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-402-2258
Mailing Address - Street 1:701 MAIDEN CHOICE LN
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5968
Mailing Address - Country:US
Mailing Address - Phone:410-402-2258
Mailing Address - Fax:410-402-2264
Practice Address - Street 1:3000 ESSEX RD
Practice Address - Street 2:
Practice Address - City:TINTON FALLS
Practice Address - State:NJ
Practice Address - Zip Code:07753-2631
Practice Address - Country:US
Practice Address - Phone:732-643-2070
Practice Address - Fax:732-643-2015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-12
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
163WP0809X, 164W00000X
NJ207Q00000X, 213E00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, AdultGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0021873Medicaid
CK3961Medicare PIN
P00012169Medicare PIN
126597MVKMedicare PIN
055948Medicare PIN
NJ0021873Medicaid
043843QD1Medicare PIN
589600MVKMedicare PIN
CB3669Medicare PIN
022138Medicare PIN