Provider Demographics
NPI:1962794420
Name:WOODBINE FAMILY MEDICAL
Entity type:Organization
Organization Name:WOODBINE FAMILY MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-861-4241
Mailing Address - Street 1:713 DEHIRSCH AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:NJ
Mailing Address - Zip Code:08270-2339
Mailing Address - Country:US
Mailing Address - Phone:609-861-4241
Mailing Address - Fax:609-861-1071
Practice Address - Street 1:713 DEHIRSCH AVE
Practice Address - Street 2:
Practice Address - City:WOODBINE
Practice Address - State:NJ
Practice Address - Zip Code:08270-2339
Practice Address - Country:US
Practice Address - Phone:609-861-4241
Practice Address - Fax:609-861-1071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB61909207Q00000X
NJ26NN1202500363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7011008Medicaid
NJG07587Medicare UPIN
NJ7011008Medicaid