Provider Demographics
NPI:1609957976
Name:KEDERSHA, THOMAS ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ANDREW
Last Name:KEDERSHA
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 1:3403 W HURLEY POND RD
Mailing Address - Street 2:
Mailing Address - City:WALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-9606
Mailing Address - Country:US
Mailing Address - Phone:732-681-0805
Mailing Address - Fax:732-681-3426
Practice Address - Street 1:25 MULE RD
Practice Address - Street 2:SUITE B 2
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-5035
Practice Address - Country:US
Practice Address - Phone:732-349-5453
Practice Address - Fax:732-681-3426
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA37819174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC53908Medicare UPIN