Provider Demographics
NPI:1447272562
Name:SOUTH JERSEY ORAL & MAXILLOFACIAL SURGEONS, LLC
Entity type:Organization
Organization Name:SOUTH JERSEY ORAL & MAXILLOFACIAL SURGEONS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMERIGO
Authorized Official - Middle Name:
Authorized Official - Last Name:FEDELI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:609-654-1300
Mailing Address - Street 1:135 JACKSON RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-9231
Mailing Address - Country:US
Mailing Address - Phone:609-654-1300
Mailing Address - Fax:609-654-0040
Practice Address - Street 1:135 JACKSON RD
Practice Address - Street 2:SUITE A
Practice Address - City:MEDFORD
Practice Address - State:NJ
Practice Address - Zip Code:08055-9231
Practice Address - Country:US
Practice Address - Phone:609-654-1300
Practice Address - Fax:609-654-0040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7945108Medicaid
NJ026120Medicare ID - Type Unspecified