Provider Demographics
NPI:1780722314
Name:NEUROLOGY CONSULTANTS OF SOUTH JERSEY, LLC
Entity type:Organization
Organization Name:NEUROLOGY CONSULTANTS OF SOUTH JERSEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:IMAN
Authorized Official - Middle Name:SHAWKI
Authorized Official - Last Name:YOUSSEF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-653-1024
Mailing Address - Street 1:24 MARSHALL DR
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-6002
Mailing Address - Country:US
Mailing Address - Phone:609-653-1024
Mailing Address - Fax:
Practice Address - Street 1:76 W JIMMIE LEEDS RD
Practice Address - Street 2:SUITE 503
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9411
Practice Address - Country:US
Practice Address - Phone:609-748-7820
Practice Address - Fax:609-748-7825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-04
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA071531002084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical NeurophysiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8649308Medicaid
NJ050748Medicare ID - Type Unspecified
NJ8649308Medicaid