Provider Demographics
NPI:1972614022
Name:SUBURBAN NEPHROLOGY GROUP PA
Entity Type:Organization
Organization Name:SUBURBAN NEPHROLOGY GROUP PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:RAE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-389-1119
Mailing Address - Street 1:510 HAMBURG TPKE
Mailing Address - Street 2:SUITE 108
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2025
Mailing Address - Country:US
Mailing Address - Phone:973-389-1119
Mailing Address - Fax:973-389-1145
Practice Address - Street 1:510 HAMBURG TPKE
Practice Address - Street 2:SUITE 108
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2025
Practice Address - Country:US
Practice Address - Phone:973-389-1119
Practice Address - Fax:973-389-1145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty