Basic Information
| Provider Information | |||||||||
| NPI: | 1659656395 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOURDES MEDICAL ASSOCIATES, PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 GROVE ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | HADDON HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080351761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567969200 | ||||||||
| FaxNumber: | 8567969397 | ||||||||
| Practice Location | |||||||||
| Address1: | 728 MARNE HWY STE 100B | ||||||||
| Address2: | |||||||||
| City: | MOORESTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080573128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562356600 | ||||||||
| FaxNumber: | 8562356610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2011 | ||||||||
| LastUpdateDate: | 10/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | FOX | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8567969200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOURDES MEDICAL ASSOCIATES, PA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MB04640900 | NJ | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6535704 | 05 | NJ | MEDICAID |