Basic Information
| Provider Information | |||||||||
| NPI: | 1801279534 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BANCROFT | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BANCROFT-LAKESIDE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1255 CALDWELL ROAD | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563484011 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6 COMMISSIONER'S PIKE | ||||||||
| Address2: | |||||||||
| City: | WOODSTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568236100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2015 | ||||||||
| LastUpdateDate: | 07/26/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARTMAN | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8563481181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 186396 | 05 | NJ | MEDICAID |