Provider Demographics
NPI:1154376903
Name:MOORESTOWN FAMILY PRACTICE, P.C.
Entity type:Organization
Organization Name:MOORESTOWN FAMILY PRACTICE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:R. BLAIR
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMERSGILL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-234-2101
Mailing Address - Street 1:301 N CHURCH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-2498
Mailing Address - Country:US
Mailing Address - Phone:856-234-2101
Mailing Address - Fax:
Practice Address - Street 1:301 N CHURCH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-2498
Practice Address - Country:US
Practice Address - Phone:856-234-2101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA39828207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ540784Medicare ID - Type UnspecifiedGROUP LEGACY NUMBER