Provider Demographics
NPI:1417273616
Name:ATLANTIC SHORE FAMILY PRACTICE, P.A.
Entity Type:Organization
Organization Name:ATLANTIC SHORE FAMILY PRACTICE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KADER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-272-1441
Mailing Address - Street 1:1423 TILTON RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-1865
Mailing Address - Country:US
Mailing Address - Phone:609-272-1441
Mailing Address - Fax:609-272-8306
Practice Address - Street 1:1423 TILTON RD
Practice Address - Street 2:SUITE 3
Practice Address - City:NORTHFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08225-1865
Practice Address - Country:US
Practice Address - Phone:609-272-1441
Practice Address - Fax:609-272-8306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-13
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB53762261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4621905Medicaid
NJ641638Medicare PIN