Provider Demographics
NPI:1205443405
Name:LIPOLASER OF SOUTH JERSEY PC
Entity type:Organization
Organization Name:LIPOLASER OF SOUTH JERSEY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:PISTONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-983-3600
Mailing Address - Street 1:100 CENTRE BLVD STE 100E
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-4128
Mailing Address - Country:US
Mailing Address - Phone:856-983-3600
Mailing Address - Fax:
Practice Address - Street 1:100 CENTRE BLVD STE 100E
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4128
Practice Address - Country:US
Practice Address - Phone:856-983-3600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty