Provider Demographics
NPI:1952739690
Name:NJ SOUTH COAST MEDICAL CENTER CORP
Entity Type:Organization
Organization Name:NJ SOUTH COAST MEDICAL CENTER CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EBERE
Authorized Official - Middle Name:
Authorized Official - Last Name:EZEANYA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-704-5644
Mailing Address - Street 1:4995 DERBY LN
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18020-9418
Mailing Address - Country:US
Mailing Address - Phone:973-704-5644
Mailing Address - Fax:
Practice Address - Street 1:37 MAIN ST STE 5
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NJ
Practice Address - Zip Code:08809
Practice Address - Country:US
Practice Address - Phone:609-582-0899
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-15
Last Update Date:2019-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA09219400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0357367Medicaid