Provider Demographics
NPI:1518184811
Name:CMC DEPT OF MEDICINE GROUP PA
Entity Type:Organization
Organization Name:CMC DEPT OF MEDICINE GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP MANAGED CARE
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMULLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-342-2921
Mailing Address - Street 1:3 COOPER PLZ
Mailing Address - Street 2:SUITE 502
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1438
Mailing Address - Country:US
Mailing Address - Phone:856-342-2921
Mailing Address - Fax:856-968-8499
Practice Address - Street 1:14 S BROADWAY
Practice Address - Street 2:
Practice Address - City:GLOUCESTER CITY
Practice Address - State:NJ
Practice Address - Zip Code:08030-1706
Practice Address - Country:US
Practice Address - Phone:856-456-0518
Practice Address - Fax:856-456-4359
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2009-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2821317000OtherAMERIHEALTH GRP#
NJ2821317000OtherAMERIHEALTH GRP#