Basic Information
| Provider Information | |||||||||
| NPI: | 1770594053 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVOCARE, LLC | ||||||||
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| OtherOrganizationName: | ADVOCARE BROOMALL PEDIATRIC ASSOCIATES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 ROUTE 73 N STE 320 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080533426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8568727055 | ||||||||
| FaxNumber: | 8565048029 | ||||||||
| Practice Location | |||||||||
| Address1: | 1246 W CHESTER PIKE | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | WEST CHESTER | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193825683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6106922605 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 11/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | MCQUEARY | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8567823300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADVOCARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/22/2021 | ||||||||
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 | 39D0203503 | 01 | CLIA | OTHER |