Provider Demographics
NPI:1386652808
Name:ONSITE NEONATAL PA
Entity Type:Organization
Organization Name:ONSITE NEONATAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:JACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-782-2212
Mailing Address - Street 1:1000 HADDONFIELD BERLIN RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-3520
Mailing Address - Country:US
Mailing Address - Phone:856-782-2212
Mailing Address - Fax:856-782-2213
Practice Address - Street 1:1000 HADDONFIELD BERLIN RD
Practice Address - Street 2:SUITE 210
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-3520
Practice Address - Country:US
Practice Address - Phone:856-782-2212
Practice Address - Fax:856-782-2213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7009801Medicaid