MEDICARE: SICKLERVILLE INTERNAL MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1821045428
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SICKLERVILLE INTERNAL MEDICINE

Provider Business Mailing Address
First Line	:	1405 CHEWS LANDING RD
Second Line	:	STE. 14
City	:	LAUREL SPRINGS
State	:	NJ
Zip	:	08021-2769
Country	:	US
Telephone Number	:	856-227-6575
Fax Number	:	856-374-9495

Provider Business Practice Location Address
First Line	:	1405 CHEWS LANDING RD
Second Line	:	STE. 14
City	:	LAUREL SPRINGS
State	:	NJ
Zip	:	08021-2769
Country	:	US
Telephone Number	:	856-227-6575
Fax Number	:	856-374-9495

Authorized Official
Title or Position	:	CREDENTIALING CONSULTANT
Name	:	MS. JOAN WENSAUER
Credential	:	BA
Telephone Number	:	856-782-3300

Provider Enumeration Date	:	05/28/2006
Last Update Date	:	11/13/2007

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Practice Location Address:

1405 CHEWS LANDING RD , SUITE 14
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08021-2769

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1104897370 — DR. SHANTHI SUBBIAH MD
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1790737963 — THERESA SOUTAR R.N. APN-C
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08021-2769

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1659323822 — MARISA CINALLI MSN,RN,APN-C
Practice Location Address:

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1558314641 — DR. QUE-CHI VUONG WONG M.D.
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1114968716 — JAMES A PRATE O.D.
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Practice Fax:

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