Provider Demographics
NPI:1538114327
Name:LOURDES PERINATOLOGY SERVICES
Entity Type:Organization
Organization Name:LOURDES PERINATOLOGY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:S
Authorized Official - Last Name:KONCHAK
Authorized Official - Suffix:
Authorized Official - Credentials:D O
Authorized Official - Phone:856-757-3993
Mailing Address - Street 1:1600 HADDON AVE
Mailing Address - Street 2:PERINATOLOGY
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-3101
Mailing Address - Country:US
Mailing Address - Phone:856-757-3993
Mailing Address - Fax:856-757-3045
Practice Address - Street 1:1600 HADDON AVE
Practice Address - Street 2:PERINATOLOGY
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-3101
Practice Address - Country:US
Practice Address - Phone:856-757-3993
Practice Address - Fax:856-757-3045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06099100207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3197603Medicaid