=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306829239
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNGENE GRACE ANTHONY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2005
-----------------------------------------------------
Last Update Date | 09/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 530 MAIN ST SUITE 4A
-----------------------------------------------------
City | CHESTER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07930-2669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 908-879-4300
-----------------------------------------------------
Fax | 908-879-8956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3001
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-0598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-782-3300
-----------------------------------------------------
Fax | 856-504-8029
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MD11471
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MA08246800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------