Healthcare Provider Details

I. General information

NPI: 1194796425
Provider Name (Legal Business Name): ROWANSOM NMI HEADACHE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 E LAUREL RD UDP #1700
STRATFORD NJ
08084-1354
US

IV. Provider business mailing address

PO BOX 635
BELLMAWR NJ
08099-0635
US

V. Phone/Fax

Practice location:
  • Phone: 856-566-7010
  • Fax: 856-566-6956
Mailing address:
  • Phone: 856-566-6706
  • Fax: 856-566-2797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL RIEKER
Title or Position: INTERIM CHIEF FINANCIAL OFFICIER
Credential:
Phone: 856-770-5729