Provider Demographics
NPI:1215187141
Name:LOURDES PERINATOLOGY SERVICES
Entity Type:Organization
Organization Name:LOURDES PERINATOLOGY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:KONCHAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-757-3993
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:08035-1736
Mailing Address - Country:US
Mailing Address - Phone:856-796-9200
Mailing Address - Fax:856-310-5603
Practice Address - Street 1:1601 HADDON AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-3109
Practice Address - Country:US
Practice Address - Phone:856-757-3993
Practice Address - Fax:856-757-3045
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOURDES PERINATOLOGY SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-29
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06099100207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3197603Medicaid