Provider Demographics
NPI:1881666105
Name:ROWANSOM NEW JERSEY INSTITUTE FOR SUCCESSFUL AGING
Entity Type:Organization
Organization Name:ROWANSOM NEW JERSEY INSTITUTE FOR SUCCESSFUL AGING
Other - Org Name:UMDNJ-SOM NEW JERSEY INSTITUTE FOR SUCCESSFUL AGING
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:INTERIM CHIEF FINANCIAL OFFICIER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:RIEKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-770-5729
Mailing Address - Street 1:PO BOX 635
Mailing Address - Street 2:
Mailing Address - City:BELLMAWR
Mailing Address - State:NJ
Mailing Address - Zip Code:08099-0635
Mailing Address - Country:US
Mailing Address - Phone:856-566-6706
Mailing Address - Fax:856-566-2797
Practice Address - Street 1:42 EAST LAUREL ROAD
Practice Address - Street 2:UDP, 1800
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084
Practice Address - Country:US
Practice Address - Phone:856-566-6843
Practice Address - Fax:856-566-6419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJCI0612OtherRAILROAD MEDICARE
NJ3407004Medicaid
NJ3407004Medicaid