Provider Demographics
NPI:1811040603
Name:CENTER CITY MEDICAL ASSOCIATES PA
Entity Type:Organization
Organization Name:CENTER CITY MEDICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-963-8907
Mailing Address - Street 1:506 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103
Mailing Address - Country:US
Mailing Address - Phone:856-963-8907
Mailing Address - Fax:856-963-9061
Practice Address - Street 1:506 BROADWAY
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103
Practice Address - Country:US
Practice Address - Phone:856-963-8907
Practice Address - Fax:856-963-9061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2009-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB02205600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2683008Medicaid
E79615Medicare UPIN
NJ2683008Medicaid