=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720084866
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HADDONFIELD FAMILY PRACTICE, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2005
-----------------------------------------------------
Last Update Date | 05/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15 E REDMAN AVE
-----------------------------------------------------
City | HADDONFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08033-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-428-1335
-----------------------------------------------------
Fax | 856-428-6334
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 E REDMAN AVE
-----------------------------------------------------
City | HADDONFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08033-2314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-428-1335
-----------------------------------------------------
Fax | 856-428-6334
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | JAMES W VICK
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 856-428-1335
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MA04041400
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------