Healthcare Provider Details

I. General information

NPI: 1790880755
Provider Name (Legal Business Name): MARK O MCCOLLUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ROBERT WOOD JOHNSON PL W WING FL 3 STE W3234
NEW BRUNSWICK NJ
08901
US

IV. Provider business mailing address

1 PERKINS SQ
AKRON OH
44308-1063
US

V. Phone/Fax

Practice location:
  • Phone: 732-828-3000
  • Fax:
Mailing address:
  • Phone: 330-543-6060
  • Fax: 330-543-8463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number25MA10025200
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA10025200
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number35.081904
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: