Basic Information
| Provider Information | |||||||||
| NPI: | 1033204052 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN'S HEALTH CARE ASSOCIATES OF NEW JERSEY PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3401 CIVIC CENTER BLVD | ||||||||
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| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191044319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259408 | ||||||||
| FaxNumber: | 2159778864 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 LAUREL OAK RD | ||||||||
| Address2: | SPECIALTY CENTER AT VOORHEES - CHOP | ||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080433505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564351300 | ||||||||
| FaxNumber: | 2159778864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 05/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | CORBO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2155672422 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 0006558520006 | 05 | PA | MEDICAID | 8241601 | 05 | NJ | MEDICAID | 0001025402 | 05 | DE | MEDICAID | 02278884 | 05 | NY | MEDICAID |