Provider Demographics
NPI:1821045428
Name:SICKLERVILLE INTERNAL MEDICINE
Entity Type:Organization
Organization Name:SICKLERVILLE INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING CONSULTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:JOAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WENSAUER
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:856-782-3300
Mailing Address - Street 1:1405 CHEWS LANDING RD
Mailing Address - Street 2:STE. 14
Mailing Address - City:LAUREL SPRINGS
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-2769
Mailing Address - Country:US
Mailing Address - Phone:856-227-6575
Mailing Address - Fax:856-374-9495
Practice Address - Street 1:1405 CHEWS LANDING RD
Practice Address - Street 2:STE. 14
Practice Address - City:LAUREL SPRINGS
Practice Address - State:NJ
Practice Address - Zip Code:08021-2769
Practice Address - Country:US
Practice Address - Phone:856-227-6575
Practice Address - Fax:856-374-9495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3279600Medicaid
NJ036054Medicare PIN