=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598874042
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXANDRE HAGEBOUTROS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/29/2006
-----------------------------------------------------
Last Update Date | 04/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 900 CENTENNIAL BLVD SUITE M
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-4689
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-325-6750
-----------------------------------------------------
Fax | 856-325-6777
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 HADDON AVE E&R BUILDING 270
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08103-1505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-963-3572
-----------------------------------------------------
Fax | 856-338-9211
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RH0003X
-----------------------------------------------------
Taxonomy Name | Hematology & Oncology Physician
-----------------------------------------------------
License Number | MA60394
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------