NPIMap

Individual provider Active NPI

Tara L. Wyche-Bullock, M.D.

  • Family Medicine Physician
  • Sicklerville, NJ
National Provider Identifier
1720008931
Registry record updated Jan 7, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
25MA07694800 Issued in NJ
Practice address
485 Williamstown Rd
Sicklerville, NJ 08081-1777
Phone
(856) 237-8100
Fax
(856) 237-8042
NPI assigned
Jul 20, 2006
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jan 7, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 25MA07694800 NJ Primary

Addresses

Primary practice location

485 Williamstown Rd
Sicklerville, NJ 08081-1777

Mailing address

155 Bridgeton Pike
Mullica Hill, NJ 08062-2669
Phone (856) 223-0500

Other identifiers 2

IdentifierTypeStateIssuer
2030554OtherNJCIGNA
304846OtherNJAMERIGROUP

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NJ
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20041228000626 NJ Practitioner - Family Practice 9537127212 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
Other, 2001
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Inspira Health Network Medical Group PCGroup PAC ID 4880797570, 238 clinicians

Practice addresses (Care Compare)

155 Bridgeton Pike
Suite C
Mullica Hill, NJ 08062-2639
Phone (856) 994-0005

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

Practice roles

OrganizationSpecialtyStatusNew patients
Inspira Health Network Medical Group, P.C. CurrentSince Jun 1, 2013 Accepting new patients
Kennedy University Hospital Inc. Past Accepting new patients
The Cooper Health System Past Accepting new patients

Locations

1120 Delsea Dr N
Glassboro, NJ 08028
Phone (856) 205-7071

34 Colson Ln
Mullica Hill, NJ 08062
Phone (856) 223-0500

155 Bridgeton Pike
Ste C
Mullica Hill, NJ 08062
Phone (856) 223-8930

155 Bridgeton Pike
Mullica Hill, NJ 08062
Phone (856) 223-0500

1 W Broad St
Paulsboro, NJ 08066
Phone (856) 223-0436

798 Centerton Rd
Pittsgrove, NJ 08318
Phone (856) 358-6161

485 Williamstown Rd
Sicklerville, NJ 08081
Phone (856) 237-8080

75 W Red Bank Ave
Woodbury, NJ 08096
Phone (856) 853-2055

17 W Red Bank Ave
Ste 104
Woodbury, NJ 08096
Phone (856) 848-0665

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 7

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1153353600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1641513600000",
    "number": "1720008931",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "155 BRIDGETON PIKE",
            "city": "MULLICA HILL",
            "state": "NJ",
            "postal_code": "080622669",
            "telephone_number": "856-223-0500",
            "fax_number": "856-223-1098"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "485 WILLIAMSTOWN RD",
            "city": "SICKLERVILLE",
            "state": "NJ",
            "postal_code": "080811777",
            "telephone_number": "856-237-8100",
            "fax_number": "856-237-8042"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WYCHE-BULLOCK",
        "first_name": "TARA",
        "middle_name": "L.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-07-20",
        "last_updated": "2022-01-07",
        "certification_date": "2022-01-07",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "NJ",
            "license": "25MA07694800",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CIGNA",
            "identifier": "2030554",
            "state": "NJ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "AMERIGROUP",
            "identifier": "304846",
            "state": "NJ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Sicklerville, NJ

Sources for this page

Verify at the official NPI Registry.