Provider Demographics
NPI:1427622661
Name:TRABECULAR MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:TRABECULAR MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:F
Authorized Official - Last Name:HABERKERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-424-5005
Mailing Address - Street 1:2301 E EVESHAM RD STE 115
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-4509
Mailing Address - Country:US
Mailing Address - Phone:856-424-5005
Mailing Address - Fax:856-770-8271
Practice Address - Street 1:2301 E EVESHAM RD STE 115
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-4509
Practice Address - Country:US
Practice Address - Phone:856-424-5005
Practice Address - Fax:856-770-8271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-13
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2781603Medicaid