Provider Demographics
NPI:1528258191
Name:92 BRICK ROAD OPERATING COMPANY LLC
Entity type:Organization
Organization Name:92 BRICK ROAD OPERATING COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOLLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-591-5700
Mailing Address - Street 1:92 BRICK RD
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2177
Mailing Address - Country:US
Mailing Address - Phone:856-988-4100
Mailing Address - Fax:609-261-7199
Practice Address - Street 1:92 BRICK RD
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2177
Practice Address - Country:US
Practice Address - Phone:856-988-8778
Practice Address - Fax:856-988-8254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0001060000OtherAMERIHEALTH/KEYSTONE
NJ081766Medicare PIN