1477881472 NPI number — PHOENIX MEDICAL GROUP

Table of content: MRS. AMY MARIE WATTS LCSW (NPI 1386844462)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477881472 NPI number — PHOENIX MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX MEDICAL GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PHOENIX MEDICAL GROUP OF MEDFORD
Provider Other Organization Name Type Code:
4
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:
1477881472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
813 EAST GATE DRIVE
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
MOUNT LAUREL
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-231-7505
Provider Business Mailing Address Fax Number:
856-608-0501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
813 E GATE DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MOUNT LAUREL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08054-1238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-231-7505
Provider Business Practice Location Address Fax Number:
856-608-0501
Provider Enumeration Date:
12/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
OPPENHEIM
Authorized Official First Name:
JEFFREY
Authorized Official Middle Name:
CHARLES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
856-231-7505

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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