Provider Demographics
NPI:1700821352
Name:SOUTH JERSEY ANESTHESIA AND PAIN PHYSICIANS PC
Entity Type:Organization
Organization Name:SOUTH JERSEY ANESTHESIA AND PAIN PHYSICIANS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEAD OF GROUP
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAGON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-508-1260
Mailing Address - Street 1:PO BOX 95000 LB# 7785
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-0001
Mailing Address - Country:US
Mailing Address - Phone:609-841-3049
Mailing Address - Fax:856-686-5319
Practice Address - Street 1:509 N BROAD ST
Practice Address - Street 2:UNDERWOOD MEMORIAL HOSPITAL
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1617
Practice Address - Country:US
Practice Address - Phone:856-845-0100
Practice Address - Fax:856-686-5319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8065900Medicaid
NJ8065900Medicaid