Basic Information
Provider Information | |||||||||
NPI: | 1306096235 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OLLMC NEONATAL ASSOCIATES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 GROVE ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | HADDON HEIGHTS | ||||||||
State: | NJ | ||||||||
PostalCode: | 080351736 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8567969200 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 218A SUNSET RD | ||||||||
Address2: |   | ||||||||
City: | WILLINGBORO | ||||||||
State: | NJ | ||||||||
PostalCode: | 080461110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6098353175 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/29/2008 | ||||||||
LastUpdateDate: | 09/29/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FERNANDES | ||||||||
AuthorizedOfficialFirstName: | MARGARET | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OF NEONATOLOGY | ||||||||
AuthorizedOfficialTelephone: | 8567573988 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | OLLMC NEONATAL ASSOCIATES | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M. D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 25MA03693600 | NJ | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
ID | Type | State | Issuer | Description | 3169405 | 05 | NJ |   | MEDICAID |