Provider Demographics
NPI:1679522775
Name:SECOND STREET MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:SECOND STREET MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:G
Authorized Official - Last Name:WOODHAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-342-1877
Mailing Address - Street 1:386 2ND ST
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-2731
Mailing Address - Country:US
Mailing Address - Phone:201-342-1877
Mailing Address - Fax:201-342-1879
Practice Address - Street 1:386 2ND ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-2731
Practice Address - Country:US
Practice Address - Phone:201-342-1877
Practice Address - Fax:201-342-1879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA67550261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJX83358Medicare UPIN
NJ065943Medicare PIN