Provider Demographics
NPI:1275571184
Name:ELMER FAMILY PRACTICE,PC
Entity Type:Organization
Organization Name:ELMER FAMILY PRACTICE,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSLICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-358-0770
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:ELMER
Mailing Address - State:NJ
Mailing Address - Zip Code:08318-0577
Mailing Address - Country:US
Mailing Address - Phone:856-358-0770
Mailing Address - Fax:856-358-0108
Practice Address - Street 1:475 ROUTE 40
Practice Address - Street 2:
Practice Address - City:ELMER
Practice Address - State:NJ
Practice Address - Zip Code:08318-2532
Practice Address - Country:US
Practice Address - Phone:856-358-0770
Practice Address - Fax:856-358-0108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2124194001OtherAMERIHEALTH ID NUMBER
NJ4584666OtherAETNA ID NUMBER
NJ5174007Medicaid
NJ067915Medicare ID - Type UnspecifiedMEDICARE ID NUMBER