Provider Demographics
NPI:1457542532
Name:JESSIE CLAIRVIL, DO LLC
Entity Type:Organization
Organization Name:JESSIE CLAIRVIL, DO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OTOLARYNGOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLAIRVIL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-339-0800
Mailing Address - Street 1:545 BECKETT RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:SWEDESBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08085-1547
Mailing Address - Country:US
Mailing Address - Phone:856-339-0800
Mailing Address - Fax:856-339-0884
Practice Address - Street 1:545 BECKETT RD
Practice Address - Street 2:SUITE 206
Practice Address - City:SWEDESBORO
Practice Address - State:NJ
Practice Address - Zip Code:08085-1547
Practice Address - Country:US
Practice Address - Phone:856-339-0800
Practice Address - Fax:856-339-0884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07620000207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0210471Medicaid
NJ0210471Medicaid
NJ083620Medicare PIN