Provider Demographics
NPI:1346537917
Name:SOUTH MAIN MEDICAL ASSOCIATES, LLC
Entity Type:Organization
Organization Name:SOUTH MAIN MEDICAL ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:KACZAJ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-213-6080
Mailing Address - Street 1:1317 S MAIN RD
Mailing Address - Street 2:SUITE 2 C
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-6511
Mailing Address - Country:US
Mailing Address - Phone:856-213-6080
Mailing Address - Fax:856-213-6092
Practice Address - Street 1:1317 S MAIN RD
Practice Address - Street 2:SUITE 2 C
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6511
Practice Address - Country:US
Practice Address - Phone:856-213-6080
Practice Address - Fax:856-213-6092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty