Basic Information
| Provider Information | |||||||||
| NPI: | 1548430317 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LOURDES MEDICAL ASSOCIATES, PA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 500 GROVE ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HADDON HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080351702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567969200 | ||||||||
| FaxNumber: | 8567969397 | ||||||||
| Practice Location | |||||||||
| Address1: | 216 HADDON AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HADDON TOWNSHIP | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081082809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568546600 | ||||||||
| FaxNumber: | 8568546700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2008 | ||||||||
| LastUpdateDate: | 12/04/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FOX | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8567969200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOURDES MEDICAL ASSOCIATES, PA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MA06771400 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6535704 | 05 | NJ | MEDICAID |