MEDICARE: DR. SUDHA BANSAL MD

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	207R00000X	Internal Medicine Physician	25MA06499700	NJ
2	207R00000X	Internal Medicine Physician	MD059329L	PA
3	208M00000X	Hospitalist Physician	25MA06499700	NJ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P00795381	OTHER	PA	RR MEDICARE - LOWER BUCKS
3	P00765936	OTHER	PA	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	30059865	OTHER	PA	KEYSTONE MERCY-LOWER BUCKS GROUP
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	30061308	OTHER	PA	KEYSTONE MERCY

General Provider Information

NPI Number	:	1487602686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUDHA BANSAL MD

Provider Business Mailing Address
First Line	:	500 GROVE ST
Second Line	:	SUITE 100
City	:	HADDON HEIGHTS
State	:	NJ
Zip	:	08035-1761
Country	:	US
Telephone Number	:	856-796-9200
Fax Number	:	856-796-9397

Provider Business Practice Location Address
First Line	:	218A SUNSET RD
Second Line	:	LOURDES MEDICAL CENTER BURLINGTON COUNTY
City	:	WILLINGBORO
State	:	NJ
Zip	:	08046-1110
Country	:	US
Telephone Number	:	609-835-3056
Fax Number	:	609-835-3061

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	12/08/2014

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Directions to “ DR. SUDHA BANSAL MD” Practice Location

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