Provider Demographics
NPI:1689662645
Name:BOLOGNESE, RONALD J (MD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:J
Last Name:BOLOGNESE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:40 LAKE CTR
Mailing Address - Street 2:401 ROUTE 73N SUITE 201A
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-3425
Mailing Address - Country:US
Mailing Address - Phone:856-355-0340
Mailing Address - Fax:856-355-0346
Practice Address - Street 1:100 BOWMAN DRIVE
Practice Address - Street 2:
Practice Address - City:VOORHEES
Practice Address - State:NJ
Practice Address - Zip Code:08043-9612
Practice Address - Country:US
Practice Address - Phone:856-247-3328
Practice Address - Fax:856-247-3276
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA04153600207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7051603Medicaid
NJ7051603Medicaid
NJ007595Medicare PIN
NJ007595R63Medicare ID - Type Unspecified