Healthcare Provider Details

I. General information

NPI: 1609957976
Provider Name (Legal Business Name): THOMAS ANDREW KEDERSHA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 MULE RD SUITE B 2
TOMS RIVER NJ
08755-5035
US

IV. Provider business mailing address

3403 W HURLEY POND RD
WALL NJ
07719-9606
US

V. Phone/Fax

Practice location:
  • Phone: 732-349-5453
  • Fax: 732-681-3426
Mailing address:
  • Phone: 732-681-0805
  • Fax: 732-681-3426

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number25MA03781900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number25MA03781900
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA03781900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: