Provider Demographics
NPI:1992836431
Name:JERSEY REHAB PA
Entity Type:Organization
Organization Name:JERSEY REHAB PA
Other - Org Name:WESTCHESTER REHABILITATION
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GANGEMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-482-1614
Mailing Address - Street 1:234 MOUNT PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-2006
Mailing Address - Country:US
Mailing Address - Phone:973-482-1614
Mailing Address - Fax:973-485-6126
Practice Address - Street 1:77 NEWARK AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-4143
Practice Address - Country:US
Practice Address - Phone:973-844-9220
Practice Address - Fax:973-844-9221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05600600208100000X, 2081S0010X
NJ25MA06101800208100000X, 2081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1184656373OtherDR MARINI NPI
NJ1962433524OtherDR GANGEMI NPI
NJ0037435Medicaid
NJ7198302Medicaid
NJ7198302Medicaid
NJ0037435Medicaid
NJ1184656373OtherDR MARINI NPI
NJF26070Medicare UPIN