Healthcare Provider Details

I. General information

NPI: 1629005012
Provider Name (Legal Business Name): JERSEY REHAB PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 10/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 NEWARK AVE
BELLEVILLE NJ
07109-1123
US

IV. Provider business mailing address

15 NEWARK AVE
BELLEVILLE NJ
07109-1123
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 Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

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