Provider Demographics
NPI:1942534243
Name:OLLMC NEONATAL ASSOCIATES
Entity Type:Organization
Organization Name:OLLMC NEONATAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:FERNANDES
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:856-757-3988
Mailing Address - Street 1:1600 HADDON AVE
Mailing Address - Street 2:ICN
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-3101
Mailing Address - Country:US
Mailing Address - Phone:856-757-3988
Mailing Address - Fax:856-365-7868
Practice Address - Street 1:501 FRONT ST
Practice Address - Street 2:
Practice Address - City:ELMER
Practice Address - State:NJ
Practice Address - Zip Code:08318-2101
Practice Address - Country:US
Practice Address - Phone:856-363-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OLLMC NEONATAL ASSOIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-21
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA036936002080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3169405Medicaid