Healthcare Provider Details

I. General information

NPI: 1992836431
Provider Name (Legal Business Name): JERSEY REHAB PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 NEWARK AVE
BELLEVILLE NJ
07109-4143
US

IV. Provider business mailing address

234 MOUNT PROSPECT AVE
NEWARK NJ
07104-2006
US

V. Phone/Fax

Practice location:
  • Phone: 973-844-9220
  • Fax: 973-844-9221
Mailing address:
  • Phone: 973-482-1614
  • Fax: 973-485-6126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MA06101800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number25MA06101800
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number25MA05600600
License Number StateNJ
# 4
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number25MA05600600
License Number StateNJ

VIII. Authorized Official

Name: DR. EDWIN M GANGEMI
Title or Position: CREDENTIALING
Credential: MD
Phone: 973-482-1614