Basic Information
| Provider Information | |||||||||
| NPI: | 1831369750 | ||||||||
| 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: | 2475 MCCLELLAN AVE | ||||||||
| Address2: | SUITE B201 | ||||||||
| City: | PENNSAUKEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081094683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563306300 | ||||||||
| FaxNumber: | 8563306305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2008 | ||||||||
| LastUpdateDate: | 10/26/2017 | ||||||||
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| AuthorizedOfficialLastName: | FOX | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8567969200 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LOURDES MEDICAL ASSOCIATES, PA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25MA01990700 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 6535704 | 05 | NJ | MEDICAID |