Provider Demographics
NPI:1013972546
Name:ALLERGY ASTHMA AND IMMUNOLOGY MANAGEMENT PA
Entity Type:Organization
Organization Name:ALLERGY ASTHMA AND IMMUNOLOGY MANAGEMENT PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STANLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-235-2651
Mailing Address - Street 1:701 E MAIN STREET
Mailing Address - Street 2:VICTORIA MEDICAL ARTS BLDG
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057
Mailing Address - Country:US
Mailing Address - Phone:856-235-2651
Mailing Address - Fax:856-231-9812
Practice Address - Street 1:701 E MAIN STREET
Practice Address - Street 2:VICTORIA MEDICAL ARTS BLDG
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057
Practice Address - Country:US
Practice Address - Phone:856-235-2651
Practice Address - Fax:856-231-1005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02538600207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0189502Medicaid
D96511Medicare UPIN
441031013Medicare PIN
NJ138746Medicare UPIN