Provider Demographics
NPI:1215960752
Name:GARDEN STATE MEDICAL ASSOC P A
Entity type:Organization
Organization Name:GARDEN STATE MEDICAL ASSOC P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:VITO
Authorized Official - Last Name:LOMONACO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-983-2848
Mailing Address - Street 1:100 BRICK RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2146
Mailing Address - Country:US
Mailing Address - Phone:856-983-2848
Mailing Address - Fax:856-985-7645
Practice Address - Street 1:100 BRICK RD
Practice Address - Street 2:SUITE 209
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2146
Practice Address - Country:US
Practice Address - Phone:856-983-2848
Practice Address - Fax:856-985-7645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2623307Medicaid
NJ2623307Medicaid