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NPI Code Detail

MEDICARE: TARA L. WYCHE-BULLOCK M.D.

MEDICARE: TARA L. WYCHE-BULLOCK M.D.
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
1207Q00000XFamily Medicine Physician25MA07694800NJ

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
12030554OTHERNJCIGNA
2304846OTHERNJAMERIGROUP

General Provider Information

NPI Number : 1720008931
Entity Type Code : Individual
Provider Name (Legal Business Name) : TARA L. WYCHE-BULLOCK M.D.
Provider Business Mailing Address
First Line : 155 BRIDGETON PIKE
Second Line :
City : MULLICA HILL
State : NJ
Zip : 08062-2669
Country : US
Telephone Number : 856-223-0500
Fax Number : 856-223-1098
Provider Business Practice Location Address
First Line : 485 WILLIAMSTOWN RD
Second Line :
City : SICKLERVILLE
State : NJ
Zip : 08081-1777
Country : US
Telephone Number : 856-237-8100
Fax Number : 856-237-8042
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/20/2006
Last Update Date : 01/07/2022

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