Provider Demographics
NPI:1639448806
Name:INFECTIOUS DISEASE CONSULTANTS OF SOUTH JERSEY LLC
Entity Type:Organization
Organization Name:INFECTIOUS DISEASE CONSULTANTS OF SOUTH JERSEY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:609-677-1046
Mailing Address - Street 1:PO BOX 1283
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08055-6283
Mailing Address - Country:US
Mailing Address - Phone:609-677-1046
Mailing Address - Fax:609-677-1306
Practice Address - Street 1:200 TRENTON RD
Practice Address - Street 2:
Practice Address - City:BROWNS MILLS
Practice Address - State:NJ
Practice Address - Zip Code:08015-1705
Practice Address - Country:US
Practice Address - Phone:609-677-1046
Practice Address - Fax:609-677-1306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-18
Last Update Date:2011-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02594500207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty