Provider Demographics
NPI:1881694032
Name:SALEM CLINIC CORP
Entity type:Organization
Organization Name:SALEM CLINIC CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-373-9600
Mailing Address - Street 1:8 BYPASS ROAD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NJ
Mailing Address - Zip Code:08079
Mailing Address - Country:US
Mailing Address - Phone:856-935-2750
Mailing Address - Fax:856-935-0105
Practice Address - Street 1:8 BYPASS ROAD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:NJ
Practice Address - Zip Code:08079
Practice Address - Country:US
Practice Address - Phone:856-935-2750
Practice Address - Fax:856-935-0105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ497401Medicaid
NJ63920Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER