Provider Demographics
NPI:1134171150
Name:WOODBURY MEDICAL OFFICE PA
Entity type:Organization
Organization Name:WOODBURY MEDICAL OFFICE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BONETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-848-8081
Mailing Address - Street 1:50 COOPER ST
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-4618
Mailing Address - Country:US
Mailing Address - Phone:856-848-8081
Mailing Address - Fax:856-848-1577
Practice Address - Street 1:50 COOPER ST
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-4618
Practice Address - Country:US
Practice Address - Phone:856-848-8081
Practice Address - Fax:856-848-1577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-17
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA054063207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0766671001OtherAMERIHEALTH GROUP NUMBER
NJ0010148OtherAETNA GROUP NUMBER
NJ2600307Medicaid
NJ000728326Medicare ID - Type UnspecifiedMEDICARE ID#
NJ=========OtherHORIZON