Provider Demographics
NPI:1235503590
Name:SMART OF SOUTH JERSEY, LLC
Entity Type:Organization
Organization Name:SMART OF SOUTH JERSEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:COSLOP
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:609-904-3456
Mailing Address - Street 1:304 JOSEPH AVE
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-1519
Mailing Address - Country:US
Mailing Address - Phone:609-904-3456
Mailing Address - Fax:609-788-4100
Practice Address - Street 1:304 JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1519
Practice Address - Country:US
Practice Address - Phone:609-904-3456
Practice Address - Fax:609-788-4100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service