Basic Information
| Provider Information | |||||||||
| NPI: | 1013958875 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TENCH | ||||||||
| FirstName: | MAVOLA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 DELSEA DR N | ||||||||
| Address2: | |||||||||
| City: | GLASSBORO | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080281444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565820500 | ||||||||
| FaxNumber: | 8565820163 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 DELSEA DR N | ||||||||
| Address2: | |||||||||
| City: | GLASSBORO | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080281444 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565820500 | ||||||||
| FaxNumber: | 8565820163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 07/30/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MA06318700 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6971601 | 05 | NJ | MEDICAID |