Basic Information
| Provider Information | |||||||||
| NPI: | 1447394770 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITZPATRICK | ||||||||
| FirstName: | LUCRETIA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 MARYLAND FARMS STE 200 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153455400 | ||||||||
| FaxNumber: | 6153455505 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 SARASOTA PATH | ||||||||
| Address2: | |||||||||
| City: | GARNET VALLEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153455400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2007 | ||||||||
| LastUpdateDate: | 08/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | MD039709E | PA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 25MA05558100 | NJ | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 6724400 | 05 | NJ | MEDICAID |