Provider Demographics
NPI:1548454903
Name:PENNSALEM MEDICAL CENTER, INC.
Entity type:Organization
Organization Name:PENNSALEM MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:UDAY
Authorized Official - Middle Name:S
Authorized Official - Last Name:UTHAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-678-9200
Mailing Address - Street 1:244 N BROADWAY
Mailing Address - Street 2:P O BOX248
Mailing Address - City:PENNSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08070-1228
Mailing Address - Country:US
Mailing Address - Phone:856-678-9200
Mailing Address - Fax:856-678-8400
Practice Address - Street 1:244 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08070-1228
Practice Address - Country:US
Practice Address - Phone:856-678-9200
Practice Address - Fax:856-678-8400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-29
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05838200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6361609Medicaid
570369Medicare PIN
F86330Medicare UPIN