Provider Demographics
NPI:1154334811
Name:SALEM MEDICAL PROFESSIONALS, PC
Entity type:Organization
Organization Name:SALEM MEDICAL PROFESSIONALS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESDIENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:NEWSOME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-373-9600
Mailing Address - Street 1:PO BOX 504290
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-0001
Mailing Address - Country:US
Mailing Address - Phone:856-935-3285
Mailing Address - Fax:856-935-4382
Practice Address - Street 1:4 BY PASS RD
Practice Address - Street 2:SUITE 101
Practice Address - City:SALEM
Practice Address - State:NJ
Practice Address - Zip Code:08079-2053
Practice Address - Country:US
Practice Address - Phone:856-935-3285
Practice Address - Fax:856-935-4382
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SALEM MEDICAL PROVESSIONALS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
099433Medicare PIN