Provider Demographics
NPI:1457553133
Name:VENTNOR PHYSICAL MEDICINE, LLC
Entity Type:Organization
Organization Name:VENTNOR PHYSICAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDI
Authorized Official - Middle Name:L
Authorized Official - Last Name:TASSONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-927-3355
Mailing Address - Street 1:2106 NEW ROAD
Mailing Address - Street 2:SUITE E-3
Mailing Address - City:LINWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08221-1052
Mailing Address - Country:US
Mailing Address - Phone:609-927-3355
Mailing Address - Fax:609-927-3385
Practice Address - Street 1:2106 NEW ROAD
Practice Address - Street 2:SUITE E-3
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1052
Practice Address - Country:US
Practice Address - Phone:609-927-3355
Practice Address - Fax:609-927-3385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA70714174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8348804Medicaid
NJH21008Medicare UPIN
NJ8348804Medicaid