Provider Demographics
NPI:1083164305
Name:MERIDIAN MEDICAL GROUP-PEDIATRIC UROLOGY
Entity Type:Organization
Organization Name:MERIDIAN MEDICAL GROUP-PEDIATRIC UROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SABLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-776-4900
Mailing Address - Street 1:557 CRANBURY RD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-5419
Mailing Address - Country:US
Mailing Address - Phone:732-613-9144
Mailing Address - Fax:
Practice Address - Street 1:1200 JUMPING BROOK RD
Practice Address - Street 2:BLDG 5
Practice Address - City:NEPTUNE
Practice Address - State:NJ
Practice Address - Zip Code:07753-2634
Practice Address - Country:US
Practice Address - Phone:732-902-7000
Practice Address - Fax:732-481-8464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric UrologyGroup - Single Specialty