Basic Information
| Provider Information | |||||||||
| NPI: | 1629307525 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BOCHENSKI | ||||||||
| FirstName: | JACEK | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 PENN SQUARE EAST | ||||||||
| Address2: | 9TH FLOOR NORTH TOWER | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259200 | ||||||||
| FaxNumber: | 2674259299 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 BOWMAN DR | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 08043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563253000 | ||||||||
| FaxNumber: | 6092615842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/24/2009 | ||||||||
| LastUpdateDate: | 11/26/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 25MA08892700 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD441187 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1025289220003 | 05 | PA | MEDICAID |