Provider Demographics
NPI:1487723615
Name:FERNICOLA, RICHARD G (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:G
Last Name:FERNICOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:ALLENHURST
Mailing Address - State:NJ
Mailing Address - Zip Code:07711-0334
Mailing Address - Country:US
Mailing Address - Phone:732-660-0202
Mailing Address - Fax:732-660-0233
Practice Address - Street 1:1451 ROUTE 88
Practice Address - Street 2:SUITE 5
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08724-2371
Practice Address - Country:US
Practice Address - Phone:732-660-0202
Practice Address - Fax:732-660-0233
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA060824225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223661177Medicare UPIN