Provider Demographics
NPI: | 1376586487 |
---|---|
Name: | MONTICOLLO, GERARD M (DO) |
Entity Type: | Individual |
Prefix: | |
First Name: | GERARD |
Middle Name: | M |
Last Name: | MONTICOLLO |
Suffix: | |
Gender: | M |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 8505 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHERRY HILL |
Mailing Address - State: | NJ |
Mailing Address - Zip Code: | 08002-0505 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 856-755-1616 |
Mailing Address - Fax: | 856-755-1616 |
Practice Address - Street 1: | 1600 HADDON AVE |
Practice Address - Street 2: | |
Practice Address - City: | CAMDEN |
Practice Address - State: | NJ |
Practice Address - Zip Code: | 08103-3101 |
Practice Address - Country: | US |
Practice Address - Phone: | 856-757-3836 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Not Answered |
Enumeration Date: | 2006-06-14 |
Last Update Date: | 2007-07-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NJ | MBD47338 | 207LP2900X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207LP2900X | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NJ | 0009928 | Other | AETNA |
NJ | 1122473 | Other | HORIZON NJ HEALTH |
NJ | 2012707 | Medicaid | |
NJ | 2190722000 | Other | AMERIHEALTH |
NJ | 95976 | Other | AMERIGROUP |
NJ | 0009928 | Other | AETNA |
NJ | 95976 | Other | AMERIGROUP |