Basic Information
| Provider Information | |||||||||
| NPI: | 1629208012 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVOCARE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ADVOCARE MOORESTOWN FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3001 | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080430598 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567823300 | ||||||||
| FaxNumber: | 8565048029 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 N CHURCH ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | MOORESTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080572498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8562342101 | ||||||||
| FaxNumber: | 8562352244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2009 | ||||||||
| LastUpdateDate: | 09/23/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TEDESCHI | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO/ CHAIRMAN | ||||||||
| AuthorizedOfficialTelephone: | 8567823300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVOCARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 31D0118892 | 01 | CLIA | OTHER |