Basic Information
Provider Information | |||||||||
NPI: | 1194979625 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OUR LADY OF LOURDES MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OLOLMC SURGICAL ASSOCIATES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 GROVE ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | HADDON HEIGHTS | ||||||||
State: | NJ | ||||||||
PostalCode: | 080351736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8567969207 | ||||||||
FaxNumber: | 8563105603 | ||||||||
Practice Location | |||||||||
Address1: | 120 WHITE HORSE PIKE | ||||||||
Address2: | SUITE 103 | ||||||||
City: | HADDON HEIGHTS | ||||||||
State: | NJ | ||||||||
PostalCode: | 080351927 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8565463900 | ||||||||
FaxNumber: | 8565463908 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/11/2008 | ||||||||
LastUpdateDate: | 11/11/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GUARNI | ||||||||
AuthorizedOfficialFirstName: | ANDREW | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 8568243027 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | OUR LADY OF LOURDES MEDICAL CENTER | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 25MA05349300 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.