Provider Demographics
NPI:1750426151
Name:PREMIER ORTHOPAEDIC OF SOUTH JERSEY
Entity type:Organization
Organization Name:PREMIER ORTHOPAEDIC OF SOUTH JERSEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:M
Authorized Official - Last Name:LIPSCHULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-853-8004
Mailing Address - Street 1:1007 MANTUA PIKE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-3963
Mailing Address - Country:US
Mailing Address - Phone:856-853-8004
Mailing Address - Fax:856-853-8022
Practice Address - Street 1:1007 MANTUA PIKE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-3963
Practice Address - Country:US
Practice Address - Phone:856-853-8004
Practice Address - Fax:856-853-8022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA054868207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2423391000OtherINDEPENDENCE BLUE CROSS
NJ1124197942Medicaid
NJ610073OtherADMINISTRATORS
NJ1271200OtherCIGNA
NJ7002746OtherAETNA
NJ2423391000OtherAMERIHEALTH
NJ2423391000OtherKEYSTONE
NJ2423391000OtherINDEPENDENCE BLUE CROSS
NJ2423391000OtherKEYSTONE
NJ1271200OtherCIGNA