Healthcare Provider Details

I. General information

NPI: 1750336392
Provider Name (Legal Business Name): GLENDORA FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 01/02/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 BLACK HORSE PIKE
GLENDORA NJ
08029-1308
US

IV. Provider business mailing address

1300 BLACK HORSE PIKE
GLENDORA NJ
08029-1308
US

V. Phone/Fax

Practice location:
  • Phone: 856-939-2828
  • Fax: 856-939-5057
Mailing address:
  • Phone: 856-939-2828
  • Fax: 856-939-5057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MB06092600
License Number StateNJ

VIII. Authorized Official

Name: DR. BENJAMIN IRA BLANK
Title or Position: PRESIDENT
Credential: DO
Phone: 856-939-2828