=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356557805
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAEGAN NICHOLE KOTSKO M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/14/2007
-----------------------------------------------------
Last Update Date | 12/13/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 HADDON AVE DEPARTMENT OF OB GYN
-----------------------------------------------------
City | CAMDEN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08103-3101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-757-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 GROVE ST SUITE 100
-----------------------------------------------------
City | HADDON HEIGHTS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08035-1702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-796-9200
-----------------------------------------------------
Fax | 856-310-5603
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 25MA08291900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------