Basic Information
| Provider Information | |||||||||
| NPI: | 1376582734 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COLYER-AVERSA | ||||||||
| FirstName: | LORI | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | LB 7550 PO BOX 95000 | ||||||||
| Address2: | |||||||||
| City: | PHILADEPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191957550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443621735 | ||||||||
| FaxNumber: | 9732907495 | ||||||||
| Practice Location | |||||||||
| Address1: | 399 HOOVER AVE | ||||||||
| Address2: | SUITE 5 | ||||||||
| City: | BLOOMFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070033924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737489500 | ||||||||
| FaxNumber: | 9737489492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 12/12/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25MA58011 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 5553903-01 | 05 | NJ | MEDICAID |