Provider Demographics
NPI: | 1497782940 |
---|---|
Name: | AGESEN, THOMAS (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | THOMAS |
Middle Name: | |
Last Name: | AGESEN |
Suffix: | |
Gender: | M |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 299 CHERRY HILL RD STE 105 |
Mailing Address - Street 2: | |
Mailing Address - City: | PARSIPPANY |
Mailing Address - State: | NJ |
Mailing Address - Zip Code: | 07054-1124 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 973-998-8301 |
Mailing Address - Fax: | 973-998-8302 |
Practice Address - Street 1: | 299 CHERRY HILL RD STE 105 |
Practice Address - Street 2: | |
Practice Address - City: | PARSIPPANY |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 07054-1124 |
Practice Address - Country: | US |
Practice Address - Phone: | 973-998-8301 |
Practice Address - Fax: | 973-998-8302 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-27 |
Last Update Date: | 2023-02-21 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NJ | 25MA07245700 | 208100000X |
NJ | 25MA7245700 | 208100000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 208100000X | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NJ | 0004341 | Medicaid | |
H41959 | Medicare UPIN | ||
NJ | 0004341 | Medicaid | |
NJ | H41959 | Medicare UPIN | |
NJ | 049280 | Medicare ID - Type Unspecified |