=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609049345
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARLOS P. BORROMEO, JR., M.D., PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2008
-----------------------------------------------------
Last Update Date | 04/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5052 WESTFIELD AVE
-----------------------------------------------------
City | PENNSAUKEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08110-2818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-663-3725
-----------------------------------------------------
Fax | 856-663-1550
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5052 WESTFIELD AVE
-----------------------------------------------------
City | PENNSAUKEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08110-2818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-663-3725
-----------------------------------------------------
Fax | 856-663-1550
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. CARLOS P. BORROMEO JR.
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 856-663-3725
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 25MA02665200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------