Provider Demographics
NPI:1497925325
Name:LOURDES MEDICAL ASSOCIATES, PA
Entity Type:Organization
Organization Name:LOURDES MEDICAL ASSOCIATES, PA
Other - Org Name:LMA TRIBORO FAMILY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-796-9200
Mailing Address - Street 1:500 GROVE ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HADDON HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:08035-1702
Mailing Address - Country:US
Mailing Address - Phone:856-796-9200
Mailing Address - Fax:856-310-5603
Practice Address - Street 1:1104 ROUTE 130 N
Practice Address - Street 2:SUITE K
Practice Address - City:CINNAMINSON
Practice Address - State:NJ
Practice Address - Zip Code:08077-3032
Practice Address - Country:US
Practice Address - Phone:856-786-8010
Practice Address - Fax:856-786-0529
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOURDES MEDICAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-06
Last Update Date:2008-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB05516700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
683572Medicare PIN