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General NPI Number Information
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NPI Number | 1992836431
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Entity Type | Organization
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Legal Business Name | JERSEY REHAB PA
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Dates
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Enumeration Date | 03/08/2007
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Last Update Date | 11/01/2007
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Provider Practice Location Address
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Address Line | 77 NEWARK AVE
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City | BELLEVILLE
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State | NJ
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Zip | 07109-4143
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Country | US
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Telephone | 973-844-9220
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Fax | 973-844-9221
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Provider Business Mailing Address
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Address Line | 234 MOUNT PROSPECT AVE
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City | NEWARK
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State | NJ
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Zip | 07104-2006
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Country | US
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Telephone | 973-482-1614
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Fax | 973-485-6126
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Authorized Official
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Title or Position | CREDENTIALING
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Name | DR. EDWIN M GANGEMI
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Credential | MD
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Telephone | 973-482-1614
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 25MA06101800
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 25MA06101800
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License Number State | NJ
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Taxonomy #3
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Taxonomy Code | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 25MA05600600
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License Number State | NJ
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Taxonomy #4
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 25MA05600600
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License Number State | NJ
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