Provider Demographics
NPI:1528109428
Name:PENNSWOOD VILLAGE
Entity type:Organization
Organization Name:PENNSWOOD VILLAGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GRIFFIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:215-504-1155
Mailing Address - Street 1:309 BRIDGEBORO RD
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-1419
Mailing Address - Country:US
Mailing Address - Phone:856-439-2071
Mailing Address - Fax:856-600-6550
Practice Address - Street 1:309 BRIDGEBORO RD
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-1419
Practice Address - Country:US
Practice Address - Phone:856-439-2071
Practice Address - Fax:856-600-6550
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PENNSWOOD VILLAGE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-12
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA557986Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER