Basic Information
| Provider Information | |||||||||
| NPI: | 1346251428 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVOCARE, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ADVOCARE HADDON PEDIATRIC GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 71422 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191761422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568727055 | ||||||||
| FaxNumber: | 8565048029 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 WHITE HORSE PIKE | ||||||||
| Address2: | |||||||||
| City: | HADDON HEIGHTS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080351909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8565477300 | ||||||||
| FaxNumber: | 8565474573 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 09/16/2022 | ||||||||
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| AuthorizedOfficialLastName: | MCQUEARY | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8568727052 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVOCARE, LLC | ||||||||
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| NPICertificationDate: | 09/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 31D0118010 | 01 | CLIA | OTHER |