Provider Demographics
NPI:1811005176
Name:JERSEY SHORE UNIVERSITY MEDICAL CENTER
Entity Type:Organization
Organization Name:JERSEY SHORE UNIVERSITY MEDICAL CENTER
Other - Org Name:BEHAVIORAL HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL PROGRAM SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-869-2781
Mailing Address - Street 1:1113 MINNEHAHA TRL
Mailing Address - Street 2:
Mailing Address - City:MANASQUAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08736-2020
Mailing Address - Country:US
Mailing Address - Phone:732-223-2210
Mailing Address - Fax:
Practice Address - Street 1:1011 BOND ST
Practice Address - Street 2:
Practice Address - City:ASBURY PARK
Practice Address - State:NJ
Practice Address - Zip Code:07712-5939
Practice Address - Country:US
Practice Address - Phone:732-869-2761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SW00942700282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access