MEDICARE: EXCALIBUR HEALTHCARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0200X	Radiology Clinic/Center	25MA04604900	NJ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	G8865226	OTHER	NJ	MEDICARE PTAN

General Provider Information

NPI Number	:	1659727741
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXCALIBUR HEALTHCARE

Provider Business Mailing Address
First Line	:	1000 S LENOLA RD
Second Line	:	BUILDING ONE, SUITE 105
City	:	MAPLE SHADE
State	:	NJ
Zip	:	08052-1630
Country	:	US
Telephone Number	:	856-231-4300
Fax Number	:

Provider Business Practice Location Address
First Line	:	1000 S LENOLA RD
Second Line	:	BUILDING ONE, SUITE 105
City	:	MAPLE SHADE
State	:	NJ
Zip	:	08052-1630
Country	:	US
Telephone Number	:	856-231-4300
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS
Name	:	MS. GENNIE LEBRON
Credential	:
Telephone Number	:	856-231-4300

Provider Enumeration Date	:	05/09/2016
Last Update Date	:	05/09/2016

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Directions to “EXCALIBUR HEALTHCARE ” Practice Location

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