Provider Demographics
NPI:1134511652
Name:LOURDES MEDICAL ASSOCIATES, PA
Entity Type:Organization
Organization Name:LOURDES MEDICAL ASSOCIATES, PA
Other - Org Name:LOURDES MEDICAL ASSOCIATES HAINSPORT FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-796-9200
Mailing Address - Street 1:500 GROVE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HADDON HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08035-1761
Mailing Address - Country:US
Mailing Address - Phone:856-796-9200
Mailing Address - Fax:856-796-9397
Practice Address - Street 1:300 CREEK CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:HAINESPORT
Practice Address - State:NJ
Practice Address - Zip Code:08036-2767
Practice Address - Country:US
Practice Address - Phone:609-702-0014
Practice Address - Fax:609-702-7225
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOURDES MEDICAL ASSOCIATES, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-02-20
Last Update Date:2015-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6535704Medicaid
NJ6535704Medicaid