Provider Demographics
NPI:1649312620
Name:BURLINGTON COUNTY
Entity type:Organization
Organization Name:BURLINGTON COUNTY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:FISCAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:INGRID
Authorized Official - Middle Name:G
Authorized Official - Last Name:KOZMIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-265-5548
Mailing Address - Street 1:PO BOX 6000
Mailing Address - Street 2:
Mailing Address - City:MT. HOLLY
Mailing Address - State:NJ
Mailing Address - Zip Code:08060
Mailing Address - Country:US
Mailing Address - Phone:609-265-5548
Mailing Address - Fax:609-265-3152
Practice Address - Street 1:15 PIONEER BLVD
Practice Address - Street 2:
Practice Address - City:WESTAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08060-3825
Practice Address - Country:US
Practice Address - Phone:609-265-5548
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ70391251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0032204Medicaid
NJ0032204Medicaid
NJ9050485Medicare ID - Type UnspecifiedEMPIRE