Provider Demographics
NPI:1265416317
Name:SOUTH JERSEY NEUROCARE PA
Entity type:Organization
Organization Name:SOUTH JERSEY NEUROCARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-714-7774
Mailing Address - Street 1:520 STOKES RD
Mailing Address - Street 2:SUITE A-4
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-2904
Mailing Address - Country:US
Mailing Address - Phone:609-714-7774
Mailing Address - Fax:609-714-7775
Practice Address - Street 1:520 STOKES RD
Practice Address - Street 2:SUITE A-4
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-2904
Practice Address - Country:US
Practice Address - Phone:609-714-7774
Practice Address - Fax:609-714-7775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-02
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ498172084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ502388Medicare ID - Type Unspecified
E13943Medicare UPIN