Provider Demographics
NPI:1013238799
Name:OUR LADY OF LOURDES MEDICAL CENTER
Entity Type:Organization
Organization Name:OUR LADY OF LOURDES MEDICAL CENTER
Other - Org Name:OLOLMC INTERNAL MEDICINE HOSPITALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:HATALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-757-3500
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:08035-1761
Mailing Address - Country:US
Mailing Address - Phone:856-796-9200
Mailing Address - Fax:856-310-0592
Practice Address - Street 1:1600 HADDON AVE
Practice Address - Street 2:INTERNAL MEDICINE
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-3101
Practice Address - Country:US
Practice Address - Phone:856-757-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OUR LADY OF LOURDES MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-17
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04819100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
310069Medicare PIN