Provider Demographics
NPI:1497786719
Name:HAINESPORT FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:HAINESPORT FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MELTZER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-702-0014
Mailing Address - Street 1:301 LIPPINCOTT DR STE 410
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4197
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0330
Practice Address - Street 1:310 CREEK CROSSING BLVD
Practice Address - Street 2:
Practice Address - City:HAINESPORT
Practice Address - State:NJ
Practice Address - Zip Code:08036-2767
Practice Address - Country:US
Practice Address - Phone:609-702-0014
Practice Address - Fax:609-702-7225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ019967Medicare ID - Type Unspecified