Basic Information
| Provider Information | |||||||||
| NPI: | 1750929907 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRUE NORTH MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TRUE NORTH PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1673 | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080437673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564704776 | ||||||||
| FaxNumber: | 8566243572 | ||||||||
| Practice Location | |||||||||
| Address1: | 2510 MARYLAND RD STE 160 | ||||||||
| Address2: | |||||||||
| City: | WILLOW GROVE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190901137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2156726622 | ||||||||
| FaxNumber: | 2156726566 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/18/2019 | ||||||||
| LastUpdateDate: | 06/16/2021 | ||||||||
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| AuthorizedOfficialLastName: | PELTZMAN | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8564704776 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRUE NORTH MEDICAL GROUP, LLC | ||||||||
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| NPICertificationDate: | 06/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.