Basic Information
| Provider Information | |||||||||
| NPI: | 1356436364 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILDRENS HEALTH CARE ASSOCIATES OF NEW JERSEY PC | ||||||||
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| OtherOrganizationName: | CHCA NJ ENDOCRINOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E PENN SQ FL 9 | ||||||||
| Address2: | CHILDRENS HEALTH CARE ASSOCIATES OF NEW JERSEY PC | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259233 | ||||||||
| FaxNumber: | 2674259299 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 LAUREL OAK RD | ||||||||
| Address2: | CHOP CARE NETWORK AT VOORHEES SCC | ||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080433505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564351300 | ||||||||
| FaxNumber: | 2674259299 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 11/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | SANTA | ||||||||
| AuthorizedOfficialFirstName: | MIXZA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ENROLLMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2674259233 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0205X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
ID Information
| ID | Type | State | Issuer | Description | 0006558520006 | 05 | PA | MEDICAID | 0001025402 | 05 | DE | MEDICAID | 02278884 | 05 | NY | MEDICAID | 8241601 | 05 | NJ | MEDICAID |