Provider Demographics
NPI:1174516280
Name:OUR LADY OF LOURDES MEDICAL CENTER
Entity type:Organization
Organization Name:OUR LADY OF LOURDES MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:GUARNI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-824-3131
Mailing Address - Street 1:100 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:NJ
Mailing Address - Zip Code:08075-1181
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 GAITHER DR
Practice Address - Street 2:SUITE 172
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-1715
Practice Address - Country:US
Practice Address - Phone:856-757-3776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-24
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ10404261QE0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ313505Medicare Oscar/Certification