Provider Demographics
NPI:1558367441
Name:VINELAND MEDICAL ASSOCIATES PA
Entity Type:Organization
Organization Name:VINELAND MEDICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NARASIMHALOO
Authorized Official - Middle Name:
Authorized Official - Last Name:VENUGOPAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-696-0108
Mailing Address - Street 1:1100 E CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-5002
Mailing Address - Country:US
Mailing Address - Phone:856-696-0108
Mailing Address - Fax:856-691-1106
Practice Address - Street 1:1100 E CHESTNUT AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-5002
Practice Address - Country:US
Practice Address - Phone:856-696-0108
Practice Address - Fax:856-691-1106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02825000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2231287739OtherTIN
NJ2875501Medicaid
556620Medicare ID - Type Unspecified
2231287739OtherTIN