Provider Demographics
NPI:1043704810
Name:FAMILY LEGACY MEDICAL CARE, PA
Entity Type:Organization
Organization Name:FAMILY LEGACY MEDICAL CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PASCALE
Authorized Official - Middle Name:
Authorized Official - Last Name:FERDINAND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:908-351-6663
Mailing Address - Street 1:115 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:NJ
Mailing Address - Zip Code:07201-2417
Mailing Address - Country:US
Mailing Address - Phone:908-351-6663
Mailing Address - Fax:908-351-1760
Practice Address - Street 1:115 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07201-2417
Practice Address - Country:US
Practice Address - Phone:908-351-6663
Practice Address - Fax:908-351-1760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-15
Last Update Date:2019-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ14126510OtherCAQH
NJ10655985OtherCAQH