Basic Information
| Provider Information | |||||||||
| NPI: | 1790164101 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LOURDES MEDICAL ASSOCIATES, PA | ||||||||
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| OtherOrganizationName: | LOURDES MEDICAL ASSOCIATES WOODBURY FAMILY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 GROVE ST | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | HADDON HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080351761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567969200 | ||||||||
| FaxNumber: | 8567969397 | ||||||||
| Practice Location | |||||||||
| Address1: | 223 S EVERGREEN AVE | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080962713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563840400 | ||||||||
| FaxNumber: | 8563847771 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2015 | ||||||||
| LastUpdateDate: | 05/19/2015 | ||||||||
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| AuthorizedOfficialLastName: | FOX | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8567969200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOURDES MEDICAL ASSOCIATES, PA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 6535704 | 05 | NJ | MEDICAID |