Provider Demographics
NPI:1285742197
Name:SALEM MEDICAL PROFESSIONALS, P.C.
Entity type:Organization
Organization Name:SALEM MEDICAL PROFESSIONALS, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
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:856-241-2090
Mailing Address - Fax:856-241-2099
Practice Address - Street 1:499 BECKETT RD
Practice Address - Street 2:
Practice Address - City:LOGAN TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08085-1766
Practice Address - Country:US
Practice Address - Phone:856-241-2090
Practice Address - Fax:856-241-2099
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SALEM MEDICAL PROFESSIONALS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207Q00000X, 207R00000X, 207V00000X, 208000000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
099433Medicare PIN