Provider Demographics
NPI:1467508796
Name:CENTER FOR PEDIATRICS ADOLESCENT AND ADULT MEDICINE OF SNJ PA
Entity Type:Organization
Organization Name:CENTER FOR PEDIATRICS ADOLESCENT AND ADULT MEDICINE OF SNJ PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MIRMANESH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-985-8100
Mailing Address - Street 1:12000 LINCOLN DR W STE 311
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3405
Mailing Address - Country:US
Mailing Address - Phone:856-985-8100
Mailing Address - Fax:856-985-8374
Practice Address - Street 1:12000 LINCOLN DR W
Practice Address - Street 2:SUITE 311
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3402
Practice Address - Country:US
Practice Address - Phone:856-985-8100
Practice Address - Fax:856-985-8374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05186900208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty