MEDICARE: ATLANTIC GYNECOLOGIC ON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207VX0201X	Gynecologic Oncology Physician	MB48253	NJ

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	CG6895	OTHER	NJ	RAIL ROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1902804693
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATLANTIC GYNECOLOGIC ON

Provider Business Mailing Address
First Line	:	3349 HWY 138
Second Line	:	BLDG B SUITE F
City	:	WALL TOWNSHIP
State	:	NJ
Zip	:	07719-9671
Country	:	US
Telephone Number	:	732-280-5464
Fax Number	:	732-280-5443

Provider Business Practice Location Address
First Line	:	3349 HWY 138
Second Line	:	BLDG B SUITE F
City	:	WALL TOWNSHIP
State	:	NJ
Zip	:	07719-9671
Country	:	US
Telephone Number	:	732-280-5464
Fax Number	:	732-280-5443

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MRS. LISA ANN MENDUM
Credential	:
Telephone Number	:	732-280-5464

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	01/09/2008

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Directions to “ATLANTIC GYNECOLOGIC ON ” Practice Location

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