Provider Demographics
NPI:1013958719
Name:BRIDGETON MEDICAL ASSOCIATES PA
Entity Type:Organization
Organization Name:BRIDGETON MEDICAL ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROCCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-455-6214
Mailing Address - Street 1:105 MANHEIM AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRIDGETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08302
Mailing Address - Country:US
Mailing Address - Phone:856-455-2700
Mailing Address - Fax:856-455-7051
Practice Address - Street 1:105 MANHEIM AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:BRIDGETON
Practice Address - State:NJ
Practice Address - Zip Code:08302-2139
Practice Address - Country:US
Practice Address - Phone:856-455-2700
Practice Address - Fax:856-455-7051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8239207Medicaid
NJ8239207Medicaid