Provider Demographics
NPI:1548273865
Name:FORKED RIVER MEDICAL SPECIALISTS, P.A.
Entity type:Organization
Organization Name:FORKED RIVER MEDICAL SPECIALISTS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:
Authorized Official - Last Name:ENDE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-693-1992
Mailing Address - Street 1:P.O. BOX 567
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-0567
Mailing Address - Country:US
Mailing Address - Phone:609-693-1992
Mailing Address - Fax:609-971-3199
Practice Address - Street 1:422 WEST LACEY ROAD
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-2518
Practice Address - Country:US
Practice Address - Phone:609-693-1992
Practice Address - Fax:609-971-3199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0659703Medicaid
NJ123723OtherPTAN
NJ0659703Medicaid