Healthcare Provider Details

I. General information

NPI: 1740292119
Provider Name (Legal Business Name): ISLAND MEDICAL ASSOCIATES,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2626 TILTON RD
EGG HARBOR TWP NJ
08234-1829
US

IV. Provider business mailing address

2626 TILTON RD
EGG HARBOR TWP NJ
08234-1829
US

V. Phone/Fax

Practice location:
  • Phone: 609-568-5000
  • Fax: 609-568-5015
Mailing address:
  • Phone: 609-568-5000
  • Fax: 609-568-5015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number25MA05948800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number25MA04695100
License Number StateNJ

VIII. Authorized Official

Name: DR. PETER O KUPONIYI
Title or Position: INTERNAL MEDICINE
Credential: MD
Phone: 609-568-5000