Basic Information
| Provider Information | |||||||||
| NPI: | 1790765055 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ROWANSOM DEPT OF FAMILY PRACTICE | ||||||||
| LastName: | |||||||||
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| MiddleName: | |||||||||
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| OtherOrganizationName: | UMDNJ-SOM DEPT OF FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 635 | ||||||||
| Address2: | |||||||||
| City: | BELLMAWR | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080990635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666706 | ||||||||
| FaxNumber: | 8565662797 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 EAST LAUREL ROAD | ||||||||
| Address2: | UDP, SUITE 2100 | ||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565667020 | ||||||||
| FaxNumber: | 8565666188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2006 | ||||||||
| LastUpdateDate: | 05/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | RIEKER | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CHIEF FINANCIAL OFFICIER | ||||||||
| AuthorizedOfficialTelephone: | 8567705729 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3215709 | 05 | NJ | MEDICAID | CA1750 | 01 | NJ | RR MEDICARE | OTHER |