Provider Demographics
NPI:1841613361
Name:ATLANTICARE
Entity Type:Organization
Organization Name:ATLANTICARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:CAESAR
Authorized Official - Last Name:DETATA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-407-2273
Mailing Address - Street 1:2500 ENGLISH CREEK AVE
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-5549
Mailing Address - Country:US
Mailing Address - Phone:609-407-2273
Mailing Address - Fax:
Practice Address - Street 1:2500 ENGLISH CREEK AVE
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-5549
Practice Address - Country:US
Practice Address - Phone:609-407-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA0400540261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJC55019OtherUPIN
NJ22644986BOtherIMP