Basic Information
| Provider Information | |||||||||
| NPI: | 1124278056 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOURDES PERINATOLOGY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 GROVE ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HADDON HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080351736 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567969200 | ||||||||
| FaxNumber: | 8563105603 | ||||||||
| Practice Location | |||||||||
| Address1: | 1505 W SHERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | VINELAND | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083606912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565078500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2008 | ||||||||
| LastUpdateDate: | 09/29/2008 | ||||||||
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| AuthorizedOfficialLastName: | KONCHAK | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
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| AuthorizedOfficialTitleorPosition: | LEAD PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8567573993 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOURDES PERINATOLOGY SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VM0101X | 25MB06099100 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Maternal & Fetal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3197603 | 05 | NJ | MEDICAID |