=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245398957
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER CITY FAMILY PRACTICE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2006
-----------------------------------------------------
Last Update Date | 10/01/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2512 ATLANTIC AVE
-----------------------------------------------------
City | ATLANTIC CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08401-6502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-347-7333
-----------------------------------------------------
Fax | 609-347-1632
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2512 ATLANTIC AVE
-----------------------------------------------------
City | ATLANTIC CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08401-6502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-347-7333
-----------------------------------------------------
Fax | 609-347-1632
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. BETTY HENDRICKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 609-347-7333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------