Provider Demographics
NPI:1295879146
Name:COLON AND RECTAL SURGICAL CENTER OF SOUTH JERSEY
Entity type:Organization
Organization Name:COLON AND RECTAL SURGICAL CENTER OF SOUTH JERSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KOWALEWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-753-0913
Mailing Address - Street 1:501 OFFICE CENTER DR
Mailing Address - Street 2:SUITE 188
Mailing Address - City:FORT WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:19034-3220
Mailing Address - Country:US
Mailing Address - Phone:609-261-5550
Mailing Address - Fax:609-261-3009
Practice Address - Street 1:217 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NJ
Practice Address - Zip Code:08048-2901
Practice Address - Country:US
Practice Address - Phone:609-261-5550
Practice Address - Fax:609-261-3009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7909306Medicaid
NJ7909306Medicaid