Healthcare Provider Details

I. General information

NPI: 1023177102
Provider Name (Legal Business Name): EASTERN NEURODIAGNOSTIC ASSOC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 E EVESHAM RD PAVILLION 800 SUITE 209
VOORHEES NJ
08043-4501
US

IV. Provider business mailing address

2301 E EVESHAM RD PAVILLION 800 SUITE 209
VOORHEES NJ
08043-4501
US

V. Phone/Fax

Practice location:
  • Phone: 856-651-0060
  • Fax: 856-651-0061
Mailing address:
  • Phone: 856-651-0060
  • Fax: 856-651-0061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. SHIVA GOPAL VASISHTA
Title or Position: PRESIDENT
Credential: MD
Phone: 856-651-0060