Basic Information
Provider Information | |||||||||
NPI: | 1841246899 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | REGIONAL WOMENS HEALTH GROUP LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | RWHG GARDEN STATE OBGYN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 71404 | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191761404 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8566696050 | ||||||||
FaxNumber: | 8566510794 | ||||||||
Practice Location | |||||||||
Address1: | 2401 E EVESHAM RD STE A-1 | ||||||||
Address2: |   | ||||||||
City: | VOORHEES | ||||||||
State: | NJ | ||||||||
PostalCode: | 080439590 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8564243323 | ||||||||
FaxNumber: | 8564244994 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/25/2006 | ||||||||
LastUpdateDate: | 03/18/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 01/05/2007 | ||||||||
NPIReactivationDate: | 03/02/2007 | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DONOVAN | ||||||||
AuthorizedOfficialFirstName: | EDWARD | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | VP, REVENUE CYCLE | ||||||||
AuthorizedOfficialTelephone: | 8566696050 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/18/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 8328706 | 05 | NJ |   | MEDICAID |