Provider Demographics
NPI:1053366690
Name:INDEPENDENCE REHAB SERVICES PC
Entity type:Organization
Organization Name:INDEPENDENCE REHAB SERVICES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHIRVELL
Authorized Official - Middle Name:M
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-321-1900
Mailing Address - Street 1:1030 KINGS HWY N
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-1907
Mailing Address - Country:US
Mailing Address - Phone:856-321-1900
Mailing Address - Fax:856-321-1107
Practice Address - Street 1:1030 KINGS HWY N
Practice Address - Street 2:SUITE 210
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08034-1907
Practice Address - Country:US
Practice Address - Phone:856-321-1900
Practice Address - Fax:856-321-1107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ525894OtherAETNA USHEALTHCARE
NJ316628OtherHORIZON BCBS
NJ6337601Medicaid
NJ316628Medicare PIN