=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538138847
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUSAN M VENTRELLA D.O.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2006
-----------------------------------------------------
Last Update Date | 01/15/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 330 FRONT ST
-----------------------------------------------------
City | ELMER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08318-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-358-0770
-----------------------------------------------------
Fax | 856-358-0108
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 330 FRONT ST PO BOX 577
-----------------------------------------------------
City | ELMER
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08318-2143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-358-0770
-----------------------------------------------------
Fax | 856-358-0108
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MB57186
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------