Provider Demographics
NPI:1568409464
Name:NEPHROLOGY SERVICES MEDICAL GROUP OF NEW JERSEY
Entity Type:Organization
Organization Name:NEPHROLOGY SERVICES MEDICAL GROUP OF NEW JERSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:OTRAKJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-888-9100
Mailing Address - Street 1:721 N BEERS ST
Mailing Address - Street 2:SUITE 1F
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-1518
Mailing Address - Country:US
Mailing Address - Phone:732-888-9100
Mailing Address - Fax:732-888-5515
Practice Address - Street 1:721 N BEERS ST
Practice Address - Street 2:SUITE 1F
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1518
Practice Address - Country:US
Practice Address - Phone:732-888-9100
Practice Address - Fax:732-888-5515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-31
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04735600207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6940803Medicaid
NJ000695310Medicare ID - Type Unspecified