Provider Demographics
NPI:1407974512
Name:INTEGRATED CHILDRENS HEALTH
Entity Type:Organization
Organization Name:INTEGRATED CHILDRENS HEALTH
Other - Org Name:MOUNT LAUREL PEDIATRICS LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PEDIATRICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RAMESH
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGOTHAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:856-983-3899
Mailing Address - Street 1:41 LAS BRISAS BLVD
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-3421
Mailing Address - Country:US
Mailing Address - Phone:856-772-0483
Mailing Address - Fax:
Practice Address - Street 1:528 LIPPINCOTT DR
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-4805
Practice Address - Country:US
Practice Address - Phone:856-983-3899
Practice Address - Fax:856-983-3997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07926600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0084972Medicaid