Basic Information
Provider Information | |||||||||
NPI: | 1134143639 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DRAKE | ||||||||
FirstName: | THOMAS | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1 FEDERAL ST | ||||||||
Address2: | STE SW200 | ||||||||
City: | CAMDEN | ||||||||
State: | NJ | ||||||||
PostalCode: | 081031155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8569636888 | ||||||||
FaxNumber: | 8569636888 | ||||||||
Practice Location | |||||||||
Address1: | 3 COOPER PLZ | ||||||||
Address2: | SUITE 200 | ||||||||
City: | CAMDEN | ||||||||
State: | NJ | ||||||||
PostalCode: | 081031438 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8563422001 | ||||||||
FaxNumber: | 8569688297 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2006 | ||||||||
LastUpdateDate: | 01/12/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD420498 | PA | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 208100000X | MD420498 | PA | N |   | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |   | 208000000X | MA08907500 | NJ | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 001967371 | 05 | PA |   | MEDICAID | STATE LICENSE | 01 | NJ | MA08907500 | OTHER | 0006947 | 05 | NJ |   | MEDICAID |