Healthcare Provider Details

I. General information

NPI: 1487723615
Provider Name (Legal Business Name): RICHARD G FERNICOLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 ROUTE 88 SUITE 5
BRICK NJ
08724-2371
US

IV. Provider business mailing address

PO BOX 334
ALLENHURST NJ
07711-0334
US

V. Phone/Fax

Practice location:
  • Phone: 732-660-0202
  • Fax: 732-660-0233
Mailing address:
  • Phone: 732-660-0202
  • Fax: 732-660-0233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License NumberMA060824
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: