Basic Information
Provider Information | |||||||||
NPI: | 1003877267 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ABO | ||||||||
FirstName: | MARC | ||||||||
MiddleName: | NEAL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10 BRASS CASTLE RD | ||||||||
Address2: |   | ||||||||
City: | WASHINGTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 078826309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9088351910 | ||||||||
FaxNumber: | 9088351924 | ||||||||
Practice Location | |||||||||
Address1: | 100 COVENTRY DR | ||||||||
Address2: |   | ||||||||
City: | PHILLIPSBURG | ||||||||
State: | NJ | ||||||||
PostalCode: | 088651900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9088590034 | ||||||||
FaxNumber: | 9088593918 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/29/2006 | ||||||||
LastUpdateDate: | 02/13/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 25MA03612300 | NJ | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | P611867 | 01 | NJ | OXFORD | OTHER | 3900908 | 05 | NJ |   | MEDICAID | 1002804 | 01 | NJ | HORIZON NJ HEALTH | OTHER | 40126 | 01 | NJ | AETNA/US HEALTHCARE | OTHER | 5209956 | 01 | PA | KEYSTONE HEALTHPLANS | OTHER | 02321900 | 01 | PA | CAPITAL BLUE CROSS | OTHER |