Provider Demographics
NPI:1255492310
Name:LAVRICH, PAMELA SUE (MD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:SUE
Last Name:LAVRICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-1439
Mailing Address - Country:US
Mailing Address - Phone:201-847-9320
Mailing Address - Fax:
Practice Address - Street 1:500 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WYCKOFF
Practice Address - State:NJ
Practice Address - Zip Code:07481-1439
Practice Address - Country:US
Practice Address - Phone:201-847-9320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06387100207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7035-306Medicaid
NJ7035-306Medicaid
NJG255-92Medicare UPIN