Provider Demographics
NPI:1376575993
Name:JERSEY SHORE PODIATRIC ASSOCIATES
Entity Type:Organization
Organization Name:JERSEY SHORE PODIATRIC ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:732-974-8200
Mailing Address - Street 1:2130 HWY 35
Mailing Address - Street 2:BLDG C STE 312
Mailing Address - City:SEA GIRT
Mailing Address - State:NJ
Mailing Address - Zip Code:08750
Mailing Address - Country:US
Mailing Address - Phone:732-974-8200
Mailing Address - Fax:732-974-0190
Practice Address - Street 1:2130 HIGHWAY 35
Practice Address - Street 2:BLDG C STE 312
Practice Address - City:SEA GIRT
Practice Address - State:NJ
Practice Address - Zip Code:08750-1010
Practice Address - Country:US
Practice Address - Phone:732-974-8200
Practice Address - Fax:732-974-0190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD2271213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6920101Medicaid
NJD06605800OtherCDS NUMBER
NJMD2271OtherLICENSE NUMBER
NJMD2271OtherLICENSE NUMBER
NJMD2271OtherLICENSE NUMBER
NJSU853224Medicare ID - Type UnspecifiedMEDICARE NUMBER
NJ5249340001Medicare NSC
NJ6920101Medicaid