Provider Demographics
NPI:1922217108
Name:RICHARD G. FERNICOLA, MD
Entity Type:Organization
Organization Name:RICHARD G. FERNICOLA, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER. PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNICOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-660-0202
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:ALLENHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07711-0334
Mailing Address - Country:US
Mailing Address - Phone:732-660-0202
Mailing Address - Fax:732-660-0233
Practice Address - Street 1:1451 ROUTE 88
Practice Address - Street 2:SUITE 5
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-2371
Practice Address - Country:US
Practice Address - Phone:732-785-9552
Practice Address - Fax:732-660-0233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA060824002081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ099058Medicare ID - Type Unspecified