Provider Demographics
NPI:1679585178
Name:FAMILY MEDICINE OF LINDENWOLD LLC
Entity type:Organization
Organization Name:FAMILY MEDICINE OF LINDENWOLD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:NEIDORF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-309-0100
Mailing Address - Street 1:409 E GIBBSBORO RD
Mailing Address - Street 2:
Mailing Address - City:LINDENWOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:08021
Mailing Address - Country:US
Mailing Address - Phone:856-309-0100
Mailing Address - Fax:856-309-8827
Practice Address - Street 1:409 E GIBBSBORO RD
Practice Address - Street 2:
Practice Address - City:LINDENWOLD
Practice Address - State:NJ
Practice Address - Zip Code:08021
Practice Address - Country:US
Practice Address - Phone:856-309-0100
Practice Address - Fax:856-309-8827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2009-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04393800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0887404Medicaid
NJ632010Medicare ID - Type Unspecified
NJ0887404Medicaid