Provider Demographics
NPI:1225223852
Name:JERSEY PM & R LLC
Entity Type:Organization
Organization Name:JERSEY PM & R LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN-IN-CHARGE
Authorized Official - Prefix:DR
Authorized Official - First Name:CORAZON
Authorized Official - Middle Name:
Authorized Official - Last Name:CIPRIASO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-601-5296
Mailing Address - Street 1:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:OLD BRIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:08857-0790
Mailing Address - Country:US
Mailing Address - Phone:732-492-8241
Mailing Address - Fax:732-521-7960
Practice Address - Street 1:25 MULE ROAD
Practice Address - Street 2:SUITE B-1
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-0025
Practice Address - Country:US
Practice Address - Phone:732-492-8241
Practice Address - Fax:732-521-7960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07358200208100000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ075945Medicare PIN