Provider Demographics
NPI:1457460594
Name:MOBILE MEDICARE
Entity Type:Organization
Organization Name:MOBILE MEDICARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:TIEDEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-388-7300
Mailing Address - Street 1:67 WALNUT AVE
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-1640
Mailing Address - Country:US
Mailing Address - Phone:732-388-7300
Mailing Address - Fax:732-388-1330
Practice Address - Street 1:67 WALNUT AVE
Practice Address - Street 2:
Practice Address - City:CLARK
Practice Address - State:NJ
Practice Address - Zip Code:07066-1640
Practice Address - Country:US
Practice Address - Phone:732-388-7300
Practice Address - Fax:732-388-1330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB27483207QG0300X
NJMB53933207QG0300X
NJMB71509207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF12985Medicare UPIN
NJE06173Medicare UPIN
NJH51969Medicare UPIN