Basic Information
| Provider Information | |||||||||
| NPI: | 1700821352 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH JERSEY ANESTHESIA AND PAIN PHYSICIANS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4 FAWNWOOD DR | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080433944 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098413049 | ||||||||
| FaxNumber: | 8566865319 | ||||||||
| Practice Location | |||||||||
| Address1: | 509 N BROAD ST | ||||||||
| Address2: | UNDERWOOD MEMORIAL HOSPITAL | ||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080961617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568450100 | ||||||||
| FaxNumber: | 8566865319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 02/11/2016 | ||||||||
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| AuthorizedOfficialLastName: | DRAGON | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
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| AuthorizedOfficialTitleorPosition: | HEAD OF GROUP | ||||||||
| AuthorizedOfficialTelephone: | 6098413049 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 8065900 | 05 | NJ | MEDICAID |