=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720008931
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA L. WYCHE-BULLOCK M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 01/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 485 WILLIAMSTOWN RD
-----------------------------------------------------
City | SICKLERVILLE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08081-1777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-237-8100
-----------------------------------------------------
Fax | 856-237-8042
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 155 BRIDGETON PIKE
-----------------------------------------------------
City | MULLICA HILL
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08062-2669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-223-0500
-----------------------------------------------------
Fax | 856-223-1098
-----------------------------------------------------
=====================================================
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 | 25MA07694800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------