Provider Demographics
NPI:1932346269
Name:SOUTH JERSEY PEDIATRIC ENDOCRINOLOGY, LLC
Entity Type:Organization
Organization Name:SOUTH JERSEY PEDIATRIC ENDOCRINOLOGY, LLC
Other - Org Name:NONE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AUGUSTINE
Authorized Official - Middle Name:O
Authorized Official - Last Name:CHIKEZIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:609-204-0698
Mailing Address - Street 1:6712 WASHINGTON AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:EGG HARBOR TWP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-1999
Mailing Address - Country:US
Mailing Address - Phone:609-204-0698
Mailing Address - Fax:609-272-3099
Practice Address - Street 1:6712 WASHINGTON AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:EGG HARBOR TWP
Practice Address - State:NJ
Practice Address - Zip Code:08234-1999
Practice Address - Country:US
Practice Address - Phone:609-204-0698
Practice Address - Fax:609-272-3099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-08
Last Update Date:2009-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05978100261QE0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7848803Medicaid
H14242Medicare UPIN