Basic Information
Provider Information | |||||||||
NPI: | 1215312749 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BANCROFT NEUROHEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BANCROFT-GLENDALE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1255 CALDWELL RD | ||||||||
Address2: |   | ||||||||
City: | CHERRY HILL | ||||||||
State: | NJ | ||||||||
PostalCode: | 080343220 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8563484011 | ||||||||
FaxNumber: | 8562161269 | ||||||||
Practice Location | |||||||||
Address1: | 1000 WHITE HORSE RD STE 912 | ||||||||
Address2: |   | ||||||||
City: | VOORHEES | ||||||||
State: | NJ | ||||||||
PostalCode: | 080434415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8566519510 | ||||||||
FaxNumber: | 8566519526 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2015 | ||||||||
LastUpdateDate: | 07/26/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARTMAN | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | P | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 8563481181 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 0016501 | 05 | NJ |   | MEDICAID |