Provider Demographics
NPI:1285630087
Name:VIRTUA WILLINGBORO HOSPITAL, INC.
Entity Type:Organization
Organization Name:VIRTUA WILLINGBORO HOSPITAL, INC.
Other - Org Name:VIRTUA WILLINGBORO HOSPITAL - PSYCH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP AND COO LOURDES
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:NESSEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-835-3056
Mailing Address - Street 1:20 WEST STOW ROAD
Mailing Address - Street 2:SUITE 8 ATTN: CHRISTINE GORDON
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3160
Mailing Address - Country:US
Mailing Address - Phone:856-355-0655
Mailing Address - Fax:856-355-0621
Practice Address - Street 1:218A SUNSET ROAD
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1110
Practice Address - Country:US
Practice Address - Phone:609-835-2900
Practice Address - Fax:609-835-3061
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF LOURDES HEALTH CARE SERVICES.INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-27
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ10303273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ31S061Medicare Oscar/Certification