MEDICARE: OUR LADY OF LOURDES MEDICAL CENTER, INC

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	261QE0700X	End-Stage Renal Disease (ESRD) Treatment Clinic/Center	10404	NJ

General Provider Information

NPI Number	:	1992798995
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OUR LADY OF LOURDES MEDICAL CENTER, INC

Provider Business Mailing Address
First Line	:	100 FRONT STREET
Second Line	:
City	:	RIVERSIDE
State	:	NJ
Zip	:	08075
Country	:	US
Telephone Number	:	856-824-3460
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 HADDON AVE
Second Line	:
City	:	CAMDEN
State	:	NJ
Zip	:	08103-3101
Country	:	US
Telephone Number	:	856-757-3776
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MR. ANDREW GUARNI
Credential	:	CPA
Telephone Number	:	856-824-3131

Provider Enumeration Date	:	08/24/2005
Last Update Date	:	01/05/2018

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