Provider Demographics
NPI:1245398957
Name:CENTER CITY FAMILY PRACTICE, INC
Entity Type:Organization
Organization Name:CENTER CITY FAMILY PRACTICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-347-7333
Mailing Address - Street 1:2512 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08401-6502
Mailing Address - Country:US
Mailing Address - Phone:609-347-7333
Mailing Address - Fax:609-347-1632
Practice Address - Street 1:2512 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-6502
Practice Address - Country:US
Practice Address - Phone:609-347-7333
Practice Address - Fax:609-347-1632
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5100208Medicaid
NJ5100208Medicaid