=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669446621
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROWANSOM DEPT OF GASTROENTEROLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2006
-----------------------------------------------------
Last Update Date | 05/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 42 E LAUREL RD SUITE 3500
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08084-1354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-566-6853
-----------------------------------------------------
Fax | 856-566-7002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 42 E LAUREL RD SUITE 3500
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08084-1354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-566-6853
-----------------------------------------------------
Fax | 856-566-7002
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INTERIM CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | MICHAEL RIEKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 856-770-5729
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------