Provider Demographics
NPI:1790735017
Name:KMC EEG DEPARTMENT GROUP
Entity Type:Organization
Organization Name:KMC EEG DEPARTMENT GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:ESPOSITO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-557-7160
Mailing Address - Street 1:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:BELLMAWR
Mailing Address - State:NJ
Mailing Address - Zip Code:08099-6069
Mailing Address - Country:US
Mailing Address - Phone:732-557-7160
Mailing Address - Fax:732-557-7109
Practice Address - Street 1:600 RIVER AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5237
Practice Address - Country:US
Practice Address - Phone:732-886-4443
Practice Address - Fax:732-886-4659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7136307Medicaid
NJ7136307Medicaid