Provider Demographics
NPI:1023177102
Name:EASTERN NEURODIAGNOSTIC ASSOC PC
Entity type:Organization
Organization Name:EASTERN NEURODIAGNOSTIC ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHIVA
Authorized Official - Middle Name:GOPAL
Authorized Official - Last Name:VASISHTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-651-0060
Mailing Address - Street 1:2301 E EVESHAM RD
Mailing Address - Street 2:PAVILLION 800 SUITE 209
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4501
Mailing Address - Country:US
Mailing Address - Phone:856-651-0060
Mailing Address - Fax:856-651-0061
Practice Address - Street 1:2301 E EVESHAM RD
Practice Address - Street 2:PAVILLION 800 SUITE 209
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4501
Practice Address - Country:US
Practice Address - Phone:856-651-0060
Practice Address - Fax:856-651-0061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
035146Medicare PIN