Provider Demographics
NPI:1972553642
Name:MAINBRIDGE MEDICAL
Entity type:Organization
Organization Name:MAINBRIDGE MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:KATZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:609-877-0644
Mailing Address - Street 1:PO BOX 8627
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002-0627
Mailing Address - Country:US
Mailing Address - Phone:856-755-1616
Mailing Address - Fax:856-755-0098
Practice Address - Street 1:1 MAINBRIDGE LN
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-2103
Practice Address - Country:US
Practice Address - Phone:609-877-0646
Practice Address - Fax:609-877-0370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ019423OtherAMERIHEALTH ADMINISTRATOR
10169OtherAETNA HMO
5868520OtherAETNA PPO
NJ8159009Medicaid
NJ0471676001OtherAMERIHEALTH HMO/PPO
5868520OtherAETNA PPO