Basic Information
| Provider Information | |||||||||
| NPI: | 1932241585 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PENN FAMILY MEDICINE AT CHERRY HILL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5810 NANCY RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921212834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586252990 | ||||||||
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| Practice Location | |||||||||
| Address1: | 409 MARLTON PIKE E | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080342413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564274336 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 08/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | HEINE | ||||||||
| AuthorizedOfficialFirstName: | KENNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8586252990 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEDVANTX, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 25MA05022600 | NJ | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.