Healthcare Provider Details

I. General information

NPI: 1427398189
Provider Name (Legal Business Name): EDWARD L. LUNDY, D.O.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2013
Last Update Date: 02/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 MARKET ST
GLOUCESTER CITY NJ
08030-1847
US

IV. Provider business mailing address

1017 MARKET ST
GLOUCESTER CITY NJ
08030-1847
US

V. Phone/Fax

Practice location:
  • Phone: 856-456-1042
  • Fax: 856-546-4896
Mailing address:
  • Phone: 856-456-1042
  • Fax: 856-456-8830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMB35070
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00143400
License Number StateNJ

VIII. Authorized Official

Name: DR. EDWARD L. LUNDY
Title or Position: OWNER
Credential: D.O.
Phone: 856-456-1042