=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326187444
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN OCEAN PRIMARY CARE ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 08/01/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 53 NAUTILUS DRIVE SUITE B
-----------------------------------------------------
City | MANAHAWKIN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-978-6266
-----------------------------------------------------
Fax | 609-978-5006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53 NAUTILUS DRIVE SUITE B
-----------------------------------------------------
City | MANAHAWKIN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-978-6266
-----------------------------------------------------
Fax | 609-978-5006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING SUPERVISOR
-----------------------------------------------------
Name | MRS. SUSAN BETTINGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 609-978-6266
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------