=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063808665
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED MEDICAL CARE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2015
-----------------------------------------------------
Last Update Date | 04/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 521 S WEST AVE
-----------------------------------------------------
City | VINELAND
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08360-5249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-696-9697
-----------------------------------------------------
Fax | 856-691-0440
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 FARMINGHAM DR
-----------------------------------------------------
City | SEWELL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08080-2135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-696-9697
-----------------------------------------------------
Fax | 856-691-0440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING MANAGER
-----------------------------------------------------
Name | MRS. SHARON E DARE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 856-221-7169
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 25MA05665700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------