Basic Information
| Provider Information | |||||||||
| NPI: | 1932142031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NOLAN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 LIPPINCOTT DR STE 410 | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080534197 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563550340 | ||||||||
| FaxNumber: | 8563550330 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 HADDON AVE | ||||||||
| Address2: | ROOM 122 | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081033101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567573872 | ||||||||
| FaxNumber: | 8563654010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 10/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 25MB04857900 | NJ | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 1617206 | 05 | NJ | MEDICAID | 586404 | 01 | INDEPENDENCE BCBS | OTHER | 1092796 | 01 | NJ | HORIZON NJ HEALTH | OTHER | 2K7019 | 01 | HEALTHNET | OTHER | 0936901001 | 01 | CIGNA | OTHER | 732400 | 01 | NJ | AMERICAID | OTHER | 048137000 | 01 | AMERIHEALTH / KEYSTONE | OTHER | 250002698 | 01 | NJ | RAILROAD MEDICARE | OTHER | 4223926 | 01 | AETNA | OTHER | 222445694 | 01 | NJ | TAX ID | OTHER |