Provider Demographics
NPI:1174684781
Name:SPRINGDALE ROAD MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:SPRINGDALE ROAD MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:856-348-8444
Mailing Address - Street 1:2428 ROUTE 38
Mailing Address - Street 2:SUITE 306
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-1241
Mailing Address - Country:US
Mailing Address - Phone:856-348-8444
Mailing Address - Fax:856-348-8446
Practice Address - Street 1:2428 ROUTE 38
Practice Address - Street 2:SUITE 306
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-1241
Practice Address - Country:US
Practice Address - Phone:856-348-8444
Practice Address - Fax:856-348-8446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB02310600207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5181101Medicaid
NJ707948Medicare ID - Type Unspecified
E06161Medicare UPIN