MEDICARE: JARED STEVEN VIDELL D.O.

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
1	207RC0000X	Cardiovascular Disease Physician	OS-003830-L	PA

General Provider Information

NPI Number	:	1154397263
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JARED STEVEN VIDELL D.O.

Provider Business Mailing Address
First Line	:	115 S. AUSTIN AVENUE
Second Line	:
City	:	VENTNOR CITY
State	:	NJ
Zip	:	08406-3012
Country	:	US
Telephone Number	:	609-823-1989
Fax Number	:

Provider Business Practice Location Address
First Line	:	115 S. AUSTIN AVENUE
Second Line	:
City	:	VENTNOR CITY
State	:	NJ
Zip	:	08406-3012
Country	:	US
Telephone Number	:	609-823-1989
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2006
Last Update Date	:	06/17/2011

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