Provider Demographics
NPI:1245391051
Name:GASTROENTEROLOGY GROUP OF SOUTH JERSEY P C
Entity type:Organization
Organization Name:GASTROENTEROLOGY GROUP OF SOUTH JERSEY P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:MATUSOW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-691-1400
Mailing Address - Street 1:602 W SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-7054
Mailing Address - Country:US
Mailing Address - Phone:856-691-1400
Mailing Address - Fax:856-691-7117
Practice Address - Street 1:602 W SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-7054
Practice Address - Country:US
Practice Address - Phone:856-691-1400
Practice Address - Fax:856-691-7117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0458453OtherAETNA
NJ0185588000OtherAMERIHEALTH
NJ1055942OtherHORIZON NJ HEALTH
NJ5430208Medicaid
NJCU000003403OtherAMERICHOICE
NJ0185588000OtherAMERIHEALTH
NJ429596Medicare PIN
NJCU000003403OtherAMERICHOICE
NJ429596Medicare ID - Type Unspecified