Provider Demographics
NPI:1053368837
Name:LAKELAND CARDIOLOGY CENTER, PA
Entity type:Organization
Organization Name:LAKELAND CARDIOLOGY CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:973-334-7700
Mailing Address - Street 1:415 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07046-1723
Mailing Address - Country:US
Mailing Address - Phone:973-334-7700
Mailing Address - Fax:973-263-5225
Practice Address - Street 1:415 BOULEVARD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN LAKES
Practice Address - State:NJ
Practice Address - Zip Code:07046-1723
Practice Address - Country:US
Practice Address - Phone:973-334-7700
Practice Address - Fax:973-263-5225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ207RC0000X174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6565506Medicaid
NJ6565506Medicaid