Provider Demographics
NPI:1811020654
Name:OUR LADY OF LOURDES MEDICAL CENTER, INC
Entity Type:Organization
Organization Name:OUR LADY OF LOURDES MEDICAL CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, INTEGRATIVE HEALTH CARE
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FRIEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-833-2052
Mailing Address - Street 1:900 HADDON AVE
Mailing Address - Street 2:SUITE 136
Mailing Address - City:COLLINGSWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08108-2101
Mailing Address - Country:US
Mailing Address - Phone:856-869-3126
Mailing Address - Fax:856-833-2050
Practice Address - Street 1:900 HADDON AVE
Practice Address - Street 2:SUITE 136
Practice Address - City:COLLINGSWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08108-2101
Practice Address - Country:US
Practice Address - Phone:856-869-3126
Practice Address - Fax:856-833-2050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04483700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ25MA04483700OtherSTATE MED LICENSE #
NJ074638Medicare PIN
NJ25MA04483700OtherSTATE MED LICENSE #
NJB39967Medicare UPIN