MEDICARE: EVERGREEN MEDICAL ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	25MA04559800	NJ

General Provider Information

NPI Number	:	1184750093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN MEDICAL ASSOCIATES

Provider Business Mailing Address
First Line	:	1200 DELSEA DR
Second Line	:	SUITE 10
City	:	WESTVILLE
State	:	NJ
Zip	:	08093-2267
Country	:	US
Telephone Number	:	856-853-5888
Fax Number	:	215-523-9281

Provider Business Practice Location Address
First Line	:	1200 DELSEA DR
Second Line	:	SUITE 10
City	:	WESTVILLE
State	:	NJ
Zip	:	08093-2267
Country	:	US
Telephone Number	:	856-853-5888
Fax Number	:	215-523-9281

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. LAUREN ALTER
Credential	:	MD
Telephone Number	:	856-853-5888

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	08/22/2020

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