=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326212671
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OUR LADY OF LOURDES MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2008
-----------------------------------------------------
Last Update Date | 03/30/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 416 SICKLERVILLE RD
-----------------------------------------------------
City | SICKLERVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08081-2556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-629-1273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 GROVE ST SUITE 100
-----------------------------------------------------
City | HADDON HEIGHTS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08035-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-796-9200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | ANDREW GUARNI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 856-824-3027
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 25MA05349300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------