Basic Information
Provider Information | |||||||||
NPI: | 1538114327 | ||||||||
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: | 1600 HADDON AVE | ||||||||
Address2: | PERINATOLOGY | ||||||||
City: | CAMDEN | ||||||||
State: | NJ | ||||||||
PostalCode: | 081033101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8567573993 | ||||||||
FaxNumber: | 8567573045 | ||||||||
Practice Location | |||||||||
Address1: | 1600 HADDON AVE | ||||||||
Address2: | PERINATOLOGY | ||||||||
City: | CAMDEN | ||||||||
State: | NJ | ||||||||
PostalCode: | 081033101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8567573993 | ||||||||
FaxNumber: | 8567573045 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KONCHAK | ||||||||
AuthorizedOfficialFirstName: | PETER | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | LEAD PHYSICIAN | ||||||||
AuthorizedOfficialTelephone: | 8567573993 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D. O. | ||||||||
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 |