Provider Demographics
NPI:1285772889
Name:PODELL MEDICAL CENTER
Entity type:Organization
Organization Name:PODELL MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-218-9191
Mailing Address - Street 1:53 KOSSUTH ST
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-2660
Mailing Address - Country:US
Mailing Address - Phone:732-565-9224
Mailing Address - Fax:732-565-9225
Practice Address - Street 1:105 MORRIS AVE
Practice Address - Street 2:SUITE200
Practice Address - City:SPRINGFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07081-1327
Practice Address - Country:US
Practice Address - Phone:973-218-9191
Practice Address - Fax:973-218-1199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA27312207R00000X
363L00000X
NJ26NC04861500364S00000X, 364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Not Answered364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Multi-Specialty
Not Answered364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJPO011784Medicare ID - Type Unspecified