Provider Demographics
NPI:1760659379
Name:SENIOR CAMPUS PRIMARY CARE PHYSICIANS PC
Entity Type:Organization
Organization Name:SENIOR CAMPUS PRIMARY CARE PHYSICIANS PC
Other - Org Name:CEDAR CREST MEDICAL CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE VP, CMO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:J
Authorized Official - Last Name:NARRETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-402-2261
Mailing Address - Street 1:701 MAIDEN CHOICE LN
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5968
Mailing Address - Country:US
Mailing Address - Phone:410-402-2261
Mailing Address - Fax:410-402-2264
Practice Address - Street 1:1 CEDAR CREST DR
Practice Address - Street 2:
Practice Address - City:POMPTON PLAINS
Practice Address - State:NJ
Practice Address - Zip Code:07444-2100
Practice Address - Country:US
Practice Address - Phone:973-831-3540
Practice Address - Fax:973-831-3503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0021873Medicaid
=========OtherBCBS OF NJ
055948Medicare PIN
055382MVKMedicare PIN
CK3961Medicare PIN
CB3669Medicare PIN
NJ0021873Medicaid