Basic Information
| Provider Information | |||||||||
| NPI: | 1396257424 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BANCROFT NEUROHEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BANCROFT NEUROHEALTH-RESNICK MT LAUREL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1255 CALDWELL RD | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080343220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563243242 | ||||||||
| FaxNumber: | 8563758358 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | MOUNT LAUREL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080541108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8007745516 | ||||||||
| FaxNumber: | 8563758358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2017 | ||||||||
| LastUpdateDate: | 10/30/2017 | ||||||||
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| AuthorizedOfficialLastName: | HARTMAN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8563481196 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 261QR0400X | AT3072 | NJ | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.