=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053365973
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ON-SITE SPECIALTY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2006
-----------------------------------------------------
Last Update Date | 11/09/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3001 E EVESHAM RD ON-SITE SPECIALTY CARE-CRNP
-----------------------------------------------------
City | VOORHEES
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08043-9547
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-613-9614
-----------------------------------------------------
Fax | 253-663-7737
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15 EAST NEW CASTLE ROAD
-----------------------------------------------------
City | OCEAN CITY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08226-4725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-602-2908
-----------------------------------------------------
Fax | 856-231-9699
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | FLORIA PETILLO
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 610-613-9614
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------