MEDICARE: GERALDINE I NELSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2080A0000X	Pediatric Adolescent Medicine Physician	MA02673000	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA02673000	OTHER	NJ	MEDICAL LICENSE

General Provider Information

NPI Number	:	1538158589
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERALDINE I NELSON MD

Provider Business Mailing Address
First Line	:	330 RATZER RD
Second Line	:	SUITE D-20
City	:	WAYNE
State	:	NJ
Zip	:	07470-7702
Country	:	US
Telephone Number	:	973-835-5556
Fax Number	:	973-696-0226

Provider Business Practice Location Address
First Line	:	330 RATZER RD
Second Line	:	SUITE D-20
City	:	WAYNE
State	:	NJ
Zip	:	07470-7702
Country	:	US
Telephone Number	:	973-835-5556
Fax Number	:	973-696-0226

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/20/2005
Last Update Date	:	07/08/2007

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