Provider Demographics
NPI:1154652907
Name:CLASSIC HEALTHCARE PHYSICIANS PA
Entity Type:Organization
Organization Name:CLASSIC HEALTHCARE PHYSICIANS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:BOLICH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-653-3100
Mailing Address - Street 1:18 CLOVER HILL CIR
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TWP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-7557
Mailing Address - Country:US
Mailing Address - Phone:609-653-3100
Mailing Address - Fax:609-653-3155
Practice Address - Street 1:18 CLOVER HILL CIR
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TWP
Practice Address - State:NJ
Practice Address - Zip Code:08234-7557
Practice Address - Country:US
Practice Address - Phone:609-653-3100
Practice Address - Fax:609-653-3155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-19
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07406800207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ110246172OtherRAILROAD MEDICARE
NJ110246172OtherRAILROAD MEDICARE
NJ057567Medicare PIN