Provider Demographics
NPI:1740292119
Name:ISLAND MEDICAL ASSOCIATES,PA
Entity type:Organization
Organization Name:ISLAND MEDICAL ASSOCIATES,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERNAL MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:O
Authorized Official - Last Name:KUPONIYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-568-5000
Mailing Address - Street 1:2626 TILTON RD
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TWP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-1829
Mailing Address - Country:US
Mailing Address - Phone:609-568-5000
Mailing Address - Fax:609-568-5015
Practice Address - Street 1:2626 TILTON RD
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TWP
Practice Address - State:NJ
Practice Address - Zip Code:08234-1829
Practice Address - Country:US
Practice Address - Phone:609-568-5000
Practice Address - Fax:609-568-5015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-13
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05948800207RA0401X
NJ25MA046951002080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0042102Medicaid
NJ0042102Medicaid