Provider Demographics
NPI:1548343973
Name:NJ MED, PA
Entity type:Organization
Organization Name:NJ MED, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VIVIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAUGHNESSY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-355-8877
Mailing Address - Street 1:240 WILLIAMSON ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07202
Mailing Address - Country:US
Mailing Address - Phone:908-355-8877
Mailing Address - Fax:908-355-0017
Practice Address - Street 1:240 WILLIAMSON ST
Practice Address - Street 2:SUITE 204
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202
Practice Address - Country:US
Practice Address - Phone:908-355-8877
Practice Address - Fax:908-355-0017
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2885305Medicaid
NJ610949Medicare ID - Type Unspecified