Provider Demographics
NPI:1407007578
Name:CENTER FOR ADULT MEDICINE OF SNJ PA
Entity Type:Organization
Organization Name:CENTER FOR ADULT MEDICINE OF SNJ PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SHAHIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MIRMANESH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-985-0203
Mailing Address - Street 1:P.O. BOX 3714
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034
Mailing Address - Country:US
Mailing Address - Phone:856-985-0203
Mailing Address - Fax:856-985-0010
Practice Address - Street 1:12000 LINCOLN DR WEST
Practice Address - Street 2:405, PAVILIONS @ GREENTREE
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053
Practice Address - Country:US
Practice Address - Phone:856-985-0203
Practice Address - Fax:856-985-0010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06992000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ031442Medicare PIN
NJH03441Medicare UPIN