Basic Information
| Provider Information | |||||||||
| NPI: | 1134173834 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDREN AND ADOLESCENT RAPID EMERGENCY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 402 LIPPINCOTT DR | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080534112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567823300 | ||||||||
| FaxNumber: | 8565048029 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 CARNIE BLVD | ||||||||
| Address2: | CARES | ||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080431548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567823300 | ||||||||
| FaxNumber: | 8565048029 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 03/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | TEDESCHI | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8567823300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0204X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8751706 | 05 | NJ | MEDICAID |