Provider Demographics
NPI:1891846895
Name:CHARLES M RICHWINE IV DO, LORI TIERNO RICHWINE DO PC
Entity type:Organization
Organization Name:CHARLES M RICHWINE IV DO, LORI TIERNO RICHWINE DO PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-927-9555
Mailing Address - Street 1:3110 OCEAN HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-7734
Mailing Address - Country:US
Mailing Address - Phone:609-927-9555
Mailing Address - Fax:609-926-8902
Practice Address - Street 1:3110 OCEAN HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-7734
Practice Address - Country:US
Practice Address - Phone:609-927-9555
Practice Address - Fax:609-926-8902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB54693207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ686908S22Medicare ID - Type Unspecified
NJE98435Medicare UPIN
NJE98434Medicare UPIN
NJ082435Medicare ID - Type UnspecifiedGROUP
NJ686924S22Medicare ID - Type Unspecified