Healthcare Provider Details

I. General information

NPI: 1891846895
Provider Name (Legal Business Name): CHARLES M RICHWINE IV DO, LORI TIERNO RICHWINE DO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 05/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 OCEAN HEIGHTS AVE
EGG HARBOR TOWNSHIP NJ
08234-7734
US

IV. Provider business mailing address

3110 OCEAN HEIGHTS AVE
EGG HARBOR TOWNSHIP NJ
08234-7734
US

V. Phone/Fax

Practice location:
  • Phone: 609-927-9555
  • Fax: 609-926-8902
Mailing address:
  • Phone: 609-927-9555
  • Fax: 609-926-8902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMB54693
License Number StateNJ

VIII. Authorized Official

Name: PATRICIA A GONZALEZ
Title or Position: BILLING MANAGER
Credential:
Phone: 609-927-9555