MEDICARE: SOUTH JERSEY PEDIATRIC ENDOCRINOLOGY, LLC

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	261QE0800X	Endoscopy Clinic/Center	25MA05978100	NJ

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	:	1932346269
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH JERSEY PEDIATRIC ENDOCRINOLOGY, LLC

Provider Business Mailing Address
First Line	:	6712 WASHINGTON AVE
Second Line	:	SUITE 203
City	:	EGG HARBOR TWP
State	:	NJ
Zip	:	08234-1999
Country	:	US
Telephone Number	:	609-204-0698
Fax Number	:	609-272-3099

Provider Business Practice Location Address
First Line	:	6712 WASHINGTON AVE
Second Line	:	SUITE 203
City	:	EGG HARBOR TWP
State	:	NJ
Zip	:	08234-1999
Country	:	US
Telephone Number	:	609-204-0698
Fax Number	:	609-272-3099

Authorized Official
Title or Position	:	MEDICAL DIRECTOR
Name	:	DR. AUGUSTINE O CHIKEZIE
Credential	:	MD
Telephone Number	:	609-204-0698

Provider Enumeration Date	:	01/08/2009
Last Update Date	:	01/08/2009

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