Basic Information
| Provider Information | |||||||||
| NPI: | 1861406969 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCONLOGUE | ||||||||
| FirstName: | JOELLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 254 EASTON AVE | ||||||||
| Address2: | |||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011766 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 254 EASTON AVE | ||||||||
| Address2: | |||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7327458519 | ||||||||
| FaxNumber: | 7322200659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 02/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MA72237 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | C139774 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 8216509 | 05 | NJ | MEDICAID |