Provider Demographics
NPI:1801927397
Name:JERSEYREHAB
Entity type:Organization
Organization Name:JERSEYREHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GANGEMI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-482-1614
Mailing Address - Street 1:234 MOUNT PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-2006
Mailing Address - Country:US
Mailing Address - Phone:973-482-1614
Mailing Address - Fax:973-482-2715
Practice Address - Street 1:495 N 13TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1317
Practice Address - Country:US
Practice Address - Phone:973-268-1444
Practice Address - Fax:973-482-3004
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JERSEYREHAB
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-08
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06101800208100000X, 2081P2900X
NJ25MA056006002081S0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1184656373OtherDR MARINI NPI
NJ1962433524OtherDR GANGEMI NPI
NJ7198302Medicaid
NJ0037435Medicaid
NJ0037435Medicaid
NJ1962433524OtherDR GANGEMI NPI
NJ7198302Medicaid
NJ075747Medicare ID - Type UnspecifiedDR MARINI