Healthcare Provider Details

I. General information

NPI: 1477846046
Provider Name (Legal Business Name): BRUCE L TJADEN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2011
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 MARTER AVE STE 503 BLDG 5
MOORESTOWN NJ
08057-3120
US

IV. Provider business mailing address

1 FEDERAL ST # 200
CAMDEN NJ
08103-1088
US

V. Phone/Fax

Practice location:
  • Phone: 856-608-8840
  • Fax: 856-722-1898
Mailing address:
  • Phone: 856-356-4924
  • Fax: 713-512-7200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number94-07612
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberR4153
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number25MA10936700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: