Provider Demographics
NPI:1811298235
Name:THOMAS A. KEDERSHA, MD, PA
Entity type:Organization
Organization Name:THOMAS A. KEDERSHA, MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:KEDERSHA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-681-0805
Mailing Address - Street 1:3403 W HURLEY POND RD
Mailing Address - Street 2:
Mailing Address - City:WALL TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-9606
Mailing Address - Country:US
Mailing Address - Phone:732-681-0805
Mailing Address - Fax:732-681-3426
Practice Address - Street 1:25 MULE RD
Practice Address - Street 2:SUITE B2
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-5035
Practice Address - Country:US
Practice Address - Phone:732-349-5453
Practice Address - Fax:732-681-3426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2014-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA37819208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ084748Medicare PIN
NJC53908Medicare UPIN
NJ191185Medicare PIN