Provider Demographics
NPI:1417393943
Name:PHOENIX HOUSECALL ASSOCIATES OF SOUTH JERSEY
Entity Type:Organization
Organization Name:PHOENIX HOUSECALL ASSOCIATES OF SOUTH JERSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:YON
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-439-0060
Mailing Address - Street 1:4510 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2210
Mailing Address - Country:US
Mailing Address - Phone:856-439-0060
Mailing Address - Fax:856-452-0344
Practice Address - Street 1:4510 CHURCH RD
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-2210
Practice Address - Country:US
Practice Address - Phone:856-439-0060
Practice Address - Fax:856-452-0344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-10
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07756900207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty