Basic Information
| Provider Information | |||||||||
| NPI: | 1760578876 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATLANTIC EMERGENCY ASSOCIATES, PA - MAINLAND LOCATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6896 W. SNOWVILLE RD | ||||||||
| Address2: | |||||||||
| City: | BRECKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44141 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | JIMMIE LEEDS ROAD | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096521000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2006 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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| AuthorizedOfficialLastName: | WALSH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BUSINESS MANGER | ||||||||
| AuthorizedOfficialTelephone: | 2158716562 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 36829 | 01 | NJ | KEYSTONE MERCY | OTHER | 611602901 | 01 | NJ | ENERGY | OTHER | 0075141 | 05 | NJ | MEDICAID | 60018386 | 01 | NJ | HORIZON NJ HEALTH | OTHER | 611602901 | 01 | NJ | BLACK LUNG | OTHER | 2639764000 | 01 | NJ | AMERIHEALTH | OTHER | 30027297 | 01 | NJ | KEYSTONE MERCY | OTHER | 611602901 | 01 | NJ | LONGSHORE | OTHER | 91001879601 | 01 | NJ | AMERICHOICE | OTHER | 1105322 | 01 | NJ | AETNA | OTHER |