=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356133409
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JERSEY MED WELL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2025
-----------------------------------------------------
Last Update Date | 05/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1913 ATLANTIC AVE STE 251-A
-----------------------------------------------------
City | MANASQUAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08736-1029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-957-1342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1913 ATLANTIC AVE STE 251-A
-----------------------------------------------------
City | MANASQUAN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08736-1029
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IRA A KLEIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 201-842-3978
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------