Basic Information
Provider Information | |||||||||
NPI: | 1023098225 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PETTIGREW | ||||||||
FirstName: | ISABEL | ||||||||
MiddleName: | HILARY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 GROVE ST | ||||||||
Address2: | STE 100 | ||||||||
City: | HADDON HEIGHTS | ||||||||
State: | NJ | ||||||||
PostalCode: | 080351761 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8567969200 | ||||||||
FaxNumber: | 8567969397 | ||||||||
Practice Location | |||||||||
Address1: | 740 MARNE HWY | ||||||||
Address2: | STE 206 | ||||||||
City: | MOORESTOWN | ||||||||
State: | NJ | ||||||||
PostalCode: | 080573126 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8562346045 | ||||||||
FaxNumber: | 8562340498 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/23/2006 | ||||||||
LastUpdateDate: | 07/01/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MA04503100 | NJ | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 60089867 | 01 | NJ | HORIZON NJ HEALTH | OTHER | 3451402 | 05 | NJ |   | MEDICAID | 1443064 | 01 | NJ | CIGNA | OTHER | 100080946302 | 01 | NJ | AMERICHOICE | OTHER | 0070964000 | 01 | NJ | AMERIHEALTH | OTHER | 8386519 | 01 | NJ | AETNA | OTHER |