Healthcare Provider Details

I. General information

NPI: 1447622915
Provider Name (Legal Business Name): GARDEN STATE OBGYN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2015
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 E EVESHAM RD SUITE A
VOORHEES NJ
08043-9590
US

IV. Provider business mailing address

2401 E EVESHAM RD SUITE A
VOORHEES NJ
08043-9590
US

V. Phone/Fax

Practice location:
  • Phone: 856-424-3323
  • Fax:
Mailing address:
  • Phone: 856-424-3323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SW0102X
TaxonomyWomen's Health Clinical Nurse Specialist
License Number26NJ00597000
License Number StateNJ

VIII. Authorized Official

Name: DR. RYAN COLELLA
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 856-424-3323