Provider Demographics
NPI:1124254552
Name:PARKSIDE ADOLESCENT AND ADULT MEDICAL CLINIC
Entity type:Organization
Organization Name:PARKSIDE ADOLESCENT AND ADULT MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:SHERITA
Authorized Official - Middle Name:MONAI
Authorized Official - Last Name:LATIMORE-COLLIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-964-5569
Mailing Address - Street 1:1300 PRINCESS AVE
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-2911
Mailing Address - Country:US
Mailing Address - Phone:856-964-5569
Mailing Address - Fax:856-964-0744
Practice Address - Street 1:1300 PRINCESS AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-2911
Practice Address - Country:US
Practice Address - Phone:856-964-5569
Practice Address - Fax:856-964-0744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-29
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MAO8519200207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent MedicineGroup - Single Specialty