Provider Demographics
NPI:1124058102
Name:ELGAWLI, PHILIP (DO)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:ELGAWLI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 577
Mailing Address - Street 2:
Mailing Address - City:ELMER
Mailing Address - State:NJ
Mailing Address - Zip Code:08318-0577
Mailing Address - Country:US
Mailing Address - Phone:856-358-0770
Mailing Address - Fax:856-358-0108
Practice Address - Street 1:475 ROUTE 40
Practice Address - Street 2:
Practice Address - City:ELMER
Practice Address - State:NJ
Practice Address - Zip Code:08318-2532
Practice Address - Country:US
Practice Address - Phone:856-358-0770
Practice Address - Fax:856-358-0108
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB07793200207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0151246Medicaid
NJ104855Medicare PIN
NJ0151246Medicaid