Healthcare Provider Details

I. General information

NPI: 1174773204
Provider Name (Legal Business Name): OLLMC NEONATAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2008
Last Update Date: 09/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 W SHERMAN AVE
VINELAND NJ
08360-6912
US

IV. Provider business mailing address

500 GROVE ST SUITE 100
HADDON HEIGHTS NJ
08035-1736
US

V. Phone/Fax

Practice location:
  • Phone: 856-597-8500
  • Fax:
Mailing address:
  • Phone: 856-796-9200
  • Fax: 856-310-5603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number25MA03693600
License Number StateNJ

VIII. Authorized Official

Name: MARGARET FERNANDES
Title or Position: CHIEF OF NEONATOLOGY
Credential: M. D.
Phone: 856-757-3988