Provider Demographics
NPI:1568510568
Name:UNDERWOOD-MEMORIAL HOSPITAL
Entity type:Organization
Organization Name:UNDERWOOD-MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OOF PRACTICE MANAGEMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-845-0100
Mailing Address - Street 1:1120 DELSEA DR N
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-1444
Mailing Address - Country:US
Mailing Address - Phone:856-423-0033
Mailing Address - Fax:856-423-4444
Practice Address - Street 1:1 W BROAD ST
Practice Address - Street 2:
Practice Address - City:PAULSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08066-1527
Practice Address - Country:US
Practice Address - Phone:856-423-0033
Practice Address - Fax:856-423-4444
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7183411Medicaid
NJ7183411Medicaid