Basic Information
Provider Information | |||||||||
NPI: | 1215187141 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LOURDES PERINATOLOGY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
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: | 8567969200 | ||||||||
FaxNumber: | 8563105603 | ||||||||
Practice Location | |||||||||
Address1: | 1601 HADDON AVE | ||||||||
Address2: |   | ||||||||
City: | CAMDEN | ||||||||
State: | NJ | ||||||||
PostalCode: | 081033109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8567573993 | ||||||||
FaxNumber: | 8567573045 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2008 | ||||||||
LastUpdateDate: | 09/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KONCHAK | ||||||||
AuthorizedOfficialFirstName: | PETER | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | LEAD PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 8567573993 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | LOURDES PERINATOLOGY SERVICES | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 |