Provider Demographics
NPI:1619126984
Name:SOUTH JERSEY GASTROENTEROLOGY CONSULTANTS PA
Entity Type:Organization
Organization Name:SOUTH JERSEY GASTROENTEROLOGY CONSULTANTS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RIYADH
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMMOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-451-9395
Mailing Address - Street 1:PO BOX 183
Mailing Address - Street 2:
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302-0137
Mailing Address - Country:US
Mailing Address - Phone:856-451-9395
Mailing Address - Fax:856-451-8615
Practice Address - Street 1:1103 W SHERMAN AVE
Practice Address - Street 2:BLDG 2 UNIT A
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6915
Practice Address - Country:US
Practice Address - Phone:856-692-9900
Practice Address - Fax:856-692-9911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8752401Medicaid
NJ138424Medicare PIN