=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093751588
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEDIATRIC PULMONARY & ASTHMA ASSOCIATES OF SOUTH JERSEY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1750 ZION RD SUITE 107
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08225-1844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-677-4566
-----------------------------------------------------
Fax | 609-677-6080
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1750 ZION RD SUITE 107
-----------------------------------------------------
City | NORTHFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08225-1844
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-677-4566
-----------------------------------------------------
Fax | 609-677-6080
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | DR. JOSEPH VITO SALVIA JR.
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 609-677-4566
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0214X
-----------------------------------------------------
Taxonomy Name | Pediatric Pulmonology Physician
-----------------------------------------------------
License Number | 25MB04424900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------