Provider Demographics
NPI:1205986049
Name:MEDALLION CARE
Entity type:Organization
Organization Name:MEDALLION CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LUTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-443-0404
Mailing Address - Street 1:957 HIGHWAY 33 WEST
Mailing Address - Street 2:SWT 5
Mailing Address - City:MONROE TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08831
Mailing Address - Country:US
Mailing Address - Phone:609-443-0404
Mailing Address - Fax:609-443-6394
Practice Address - Street 1:957 HIGHWAY 33 WEST
Practice Address - Street 2:SWT 5
Practice Address - City:MONROE TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08831
Practice Address - Country:US
Practice Address - Phone:609-443-0404
Practice Address - Fax:609-443-6394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6753108Medicaid