Provider Demographics
NPI:1023041480
Name:SOUTHERN OCEAN SPECIALTY PHYSICIANS, P.C.
Entity Type:Organization
Organization Name:SOUTHERN OCEAN SPECIALTY PHYSICIANS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:NIEWIADOMSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-978-8900
Mailing Address - Street 1:1364 ROUTE 72 W
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2485
Mailing Address - Country:US
Mailing Address - Phone:609-971-7986
Mailing Address - Fax:609-597-4557
Practice Address - Street 1:1100 ROUTE 72 W
Practice Address - Street 2:SUITE 305
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2468
Practice Address - Country:US
Practice Address - Phone:609-978-3359
Practice Address - Fax:609-978-3060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0069329Medicaid
NJ091763Medicare ID - Type UnspecifiedGROUP NUMBER