Healthcare Provider Details

I. General information

NPI: 1922057231
Provider Name (Legal Business Name): MARC G BACKAL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2006
Last Update Date: 08/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 FISH POND RD
SEWELL NJ
08080-3047
US

IV. Provider business mailing address

402 LIPPINCOTT DR
MARLTON NJ
08053-4112
US

V. Phone/Fax

Practice location:
  • Phone: 856-863-9999
  • Fax: 856-863-9666
Mailing address:
  • Phone: 856-782-3300
  • Fax: 856-504-8029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA06162500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: