Healthcare Provider Details

I. General information

NPI: 1720084866
Provider Name (Legal Business Name): HADDONFIELD FAMILY PRACTICE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 05/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 E REDMAN AVE
HADDONFIELD NJ
08033-2314
US

IV. Provider business mailing address

15 E REDMAN AVE
HADDONFIELD NJ
08033-2314
US

V. Phone/Fax

Practice location:
  • Phone: 856-428-1335
  • Fax: 856-428-6334
Mailing address:
  • Phone: 856-428-1335
  • Fax: 856-428-6334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25MA04041400
License Number StateNJ

VIII. Authorized Official

Name: JAMES W VICK
Title or Position: PRESIDENT
Credential: MD
Phone: 856-428-1335