Provider Demographics
NPI:1720084866
Name:HADDONFIELD FAMILY PRACTICE, P.A.
Entity Type:Organization
Organization Name:HADDONFIELD FAMILY PRACTICE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:W
Authorized Official - Last Name:VICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-428-1335
Mailing Address - Street 1:15 E REDMAN AVE
Mailing Address - Street 2:
Mailing Address - City:HADDONFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08033-2314
Mailing Address - Country:US
Mailing Address - Phone:856-428-1335
Mailing Address - Fax:856-428-6334
Practice Address - Street 1:15 E REDMAN AVE
Practice Address - Street 2:
Practice Address - City:HADDONFIELD
Practice Address - State:NJ
Practice Address - Zip Code:08033-2314
Practice Address - Country:US
Practice Address - Phone:856-428-1335
Practice Address - Fax:856-428-6334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04041400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ557037Medicare PIN