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NPI Code Detail

MEDICARE: MARVEN WALLEN & S. KENNETH JACOBSON, MD PA

MEDICARE: MARVEN WALLEN & S. KENNETH JACOBSON, MD PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208D00000XGeneral Practice PhysicianNJ

General Provider Information

NPI Number : 1053507566
Entity Type Code : Organization
Provider Name (Legal Business Name) : MARVEN WALLEN & S. KENNETH JACOBSON, MD PA
Provider Business Mailing Address
First Line : 1985 SPRINGFIELD AVE
Second Line :
City : MAPLEWOOD
State : NJ
Zip : 07040-3435
Country : US
Telephone Number : 973-763-5010
Fax Number : 973-761-6980
Provider Business Practice Location Address
First Line : 1985 SPRINGFIELD AVE
Second Line :
City : MAPLEWOOD
State : NJ
Zip : 07040-3435
Country : US
Telephone Number : 973-763-5010
Fax Number : 973-761-6980
Authorized Official
Title or Position : OWNER/ADMINISTRATOR
Name : DR. MARVEN H WALLEN
Credential : M.D.
Telephone Number : 973-763-5010
Provider Enumeration Date : 09/18/2007
Last Update Date : 06/19/2008

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Directions to “MARVEN WALLEN & S. KENNETH JACOBSON, MD PA ” Practice Location

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