MEDICARE: LIPOLASER OF SOUTH JERSEY PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207N00000X	Dermatology Physician
2	208100000X	Physical Medicine & Rehabilitation Physician
3	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1205443405
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIPOLASER OF SOUTH JERSEY PC

Provider Business Mailing Address
First Line	:	100 CENTRE BLVD STE 100E
Second Line	:
City	:	MARLTON
State	:	NJ
Zip	:	08053-4128
Country	:	US
Telephone Number	:	856-983-3600
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 CENTRE BLVD STE 100E
Second Line	:
City	:	MARLTON
State	:	NJ
Zip	:	08053-4128
Country	:	US
Telephone Number	:	856-983-3600
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	GREGORY PISTONE
Credential	:	MD
Telephone Number	:	856-983-3600

Provider Enumeration Date	:	09/30/2020
Last Update Date	:	09/30/2020

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