Basic Information
| Provider Information | |||||||||
| NPI: | 1306167507 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOURDES MEDICAL ASSOCIATES, P. A. | ||||||||
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| OtherOrganizationName: | LOURDES MEDICAL ASSOCIATES HOSPITALIST GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 GROVE ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HADDON HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080351761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567969200 | ||||||||
| FaxNumber: | 8563100592 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 HADDON AVE | ||||||||
| Address2: | |||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081033101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567573500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2010 | ||||||||
| LastUpdateDate: | 06/22/2010 | ||||||||
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| AuthorizedOfficialLastName: | BLABER | ||||||||
| AuthorizedOfficialFirstName: | REGINALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8567969200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOURDES MEDICAL ASSOCIATES, P. A. | ||||||||
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| AuthorizedOfficialCredential: | M. D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 25MA07709400 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207V00000X | 25MB06629000 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 6535704 | 05 | NJ | MEDICAID |