Basic Information
| Provider Information | |||||||||
| NPI: | 1093761686 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REGIONAL WOMENS HEALTH GROUP LLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RWHG VIRTUA CENTER FOR WOMEN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 71421 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191761421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566696050 | ||||||||
| FaxNumber: | 8566510794 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 BOWMAN DR STE E340 | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080439636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562477600 | ||||||||
| FaxNumber: | 8562477575 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 11/05/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 01/05/2007 | ||||||||
| NPIReactivationDate: | 03/02/2007 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DONOVAN | ||||||||
| AuthorizedOfficialFirstName: | EDWARD | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | VP, REV CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 8566696050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 8328706 | 05 | NJ | MEDICAID |