Basic Information
| Provider Information | |||||||||
| NPI: | 1932495694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORDECAI | ||||||||
| FirstName: | RUSSELL | ||||||||
| MiddleName: | EVAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565666000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | STRATFORD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080841500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563466000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2011 | ||||||||
| LastUpdateDate: | 11/18/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 25MB09741200 | NJ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207P00000X | 25MB09741200 | NJ | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.