Provider Demographics
NPI:1750336392
Name:GLENDORA FAMILY PRACTICE LLC
Entity type:Organization
Organization Name:GLENDORA FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:IRA
Authorized Official - Last Name:BLANK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-939-2828
Mailing Address - Street 1:1300 BLACK HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:NJ
Mailing Address - Zip Code:08029-1308
Mailing Address - Country:US
Mailing Address - Phone:856-939-2828
Mailing Address - Fax:856-939-5057
Practice Address - Street 1:1300 BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:NJ
Practice Address - Zip Code:08029-1308
Practice Address - Country:US
Practice Address - Phone:856-939-2828
Practice Address - Fax:856-939-5057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB06092600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ870901Medicare ID - Type UnspecifiedPROVIDER NUMBER