Basic Information
| Provider Information | |||||||||
| NPI: | 1972553642 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAINBRIDGE MEDICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8627 | ||||||||
| Address2: | |||||||||
| City: | CHERRY HILL | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080020627 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567551616 | ||||||||
| FaxNumber: | 8567550098 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MAINBRIDGE LN | ||||||||
| Address2: | |||||||||
| City: | WILLINGBORO | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080462103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6098770646 | ||||||||
| FaxNumber: | 6098770370 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KATZ | ||||||||
| AuthorizedOfficialFirstName: | LEONARD | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6098770644 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 019423 | 01 | NJ | AMERIHEALTH ADMINISTRATOR | OTHER | 10169 | 01 | AETNA HMO | OTHER | 5868520 | 01 | AETNA PPO | OTHER | 8159009 | 05 | NJ | MEDICAID | 0471676001 | 01 | NJ | AMERIHEALTH HMO/PPO | OTHER |