Provider Demographics
NPI:1073683660
Name:HARBOR FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:HARBOR FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:VOGDES
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-967-0070
Mailing Address - Street 1:336 96TH ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:STONE HARBOR
Mailing Address - State:NJ
Mailing Address - Zip Code:08247-1439
Mailing Address - Country:US
Mailing Address - Phone:609-967-0070
Mailing Address - Fax:609-967-0077
Practice Address - Street 1:376 96TH ST
Practice Address - Street 2:
Practice Address - City:STONE HARBOR
Practice Address - State:NJ
Practice Address - Zip Code:08247-1404
Practice Address - Country:US
Practice Address - Phone:609-967-0070
Practice Address - Fax:609-967-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07211700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ073128Medicare ID - Type Unspecified