1346318862 NPI number — SUSAN ROSE FITZGERALD PA-C

Table of content: SUSAN ROSE FITZGERALD PA-C (NPI 1346318862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346318862 NPI number — SUSAN ROSE FITZGERALD PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
SUSAN
Provider Middle Name:
ROSE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DELIMA
Provider Other First Name:
SUSAN
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346318862
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 FEDERAL ST # 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08103-1088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-356-4924
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1935 ROUTE 70 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHERRY HILL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08003-2117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-546-8525
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/01/2006

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: 207XS0114X , with the licence number:  MA052827 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: MA052828 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 25MP00174000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MA052828 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 25 MP00174000 . This is a "NJ LICENSE #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".