1295727352 NPI number — LORI A DEPERSIA M.D.

Table of content: LORI A DEPERSIA M.D. (NPI 1295727352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295727352 NPI number — LORI A DEPERSIA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEPERSIA
Provider First Name:
LORI
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295727352
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1001 BRIGGS RD
Provider Second Line Business Mailing Address:
SUITE 210
Provider Business Mailing Address City Name:
MOUNT LAUREL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08054-4100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-231-4774
Provider Business Mailing Address Fax Number:
856-231-9699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1648 HUNTINGDON PIKE
Provider Second Line Business Practice Location Address:
RADIOLOGY DEPARTMENT
Provider Business Practice Location Address City Name:
MEADOWBROOK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19046-8001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-938-3467
Provider Business Practice Location Address Fax Number:
215-938-3474
Provider Enumeration Date:
08/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , with the licence number:  MD029084E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2085N0700X , with the licence number: MD029084E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0073256900006 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007325269 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2210703 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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