1790164101 NPI number — LOURDES MEDICAL ASSOCIATES, PA

Table of content: (NPI 1790164101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790164101 NPI number — LOURDES MEDICAL ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LOURDES MEDICAL ASSOCIATES, PA
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:
Provider Other Organization Name Type Code:
6
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:
1790164101
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 GROVE ST
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
HADDON HEIGHTS
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08035-1761
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-796-9200
Provider Business Mailing Address Fax Number:
856-796-9397

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
223 S EVERGREEN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08096-2713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-384-0400
Provider Business Practice Location Address Fax Number:
856-384-7771
Provider Enumeration Date:
05/19/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FOX
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
856-796-9200

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6535704 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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