Provider Demographics
NPI:1578563052
Name:SALEM CLINIC CORP
Entity Type:Organization
Organization Name:SALEM CLINIC CORP
Other - Org Name:CHILDREN'S HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-373-9600
Mailing Address - Street 1:4 BYPASS ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SALEM
Mailing Address - State:NJ
Mailing Address - Zip Code:08079
Mailing Address - Country:US
Mailing Address - Phone:856-935-3582
Mailing Address - Fax:856-935-4382
Practice Address - Street 1:4 BYPASS ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:SALEM
Practice Address - State:NJ
Practice Address - Zip Code:08079
Practice Address - Country:US
Practice Address - Phone:856-935-3582
Practice Address - Fax:856-935-4382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8996105Medicaid
NJ8996105Medicaid