Healthcare Provider Details

I. General information

NPI: 1669426219
Provider Name (Legal Business Name): CHARLES NICHOLAS KROME D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/02/2020
Certification Date: 08/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 MACARTHUR BLVD
SOMERS POINT NJ
08244-1776
US

IV. Provider business mailing address

24 MACARTHUR BLVD
SOMERS POINT NJ
08244-1776
US

V. Phone/Fax

Practice location:
  • Phone: 609-927-1991
  • Fax: 609-926-0075
Mailing address:
  • Phone: 609-927-1991
  • Fax: 609-926-0075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS-010745-L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number25MB07964500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: