Provider Demographics
NPI:1912911207
Name:SICKLERVILLE INTERNAL MEDICINE ASSOCIATES INC
Entity Type:Organization
Organization Name:SICKLERVILLE INTERNAL MEDICINE ASSOCIATES INC
Other - Org Name:S.I.M.A.
Other - Org Type:Other Name
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAYNARD
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLGADO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-237-8160
Mailing Address - Street 1:485 WILLIAMSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:SICKLERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08081-1777
Mailing Address - Country:US
Mailing Address - Phone:856-237-8100
Mailing Address - Fax:856-237-8142
Practice Address - Street 1:485 WILLIAMSTOWN RD
Practice Address - Street 2:
Practice Address - City:SICKLERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08081-1777
Practice Address - Country:US
Practice Address - Phone:856-237-8100
Practice Address - Fax:856-237-8142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA61324207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3279600Medicaid
NJ36054Medicare ID - Type Unspecified
NJ3279600Medicaid