Provider Demographics
NPI:1306060819
Name:MACBAIN, OPHELIA
Entity type:Individual
Prefix:
First Name:OPHELIA
Middle Name:
Last Name:MACBAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 ENGLE ST
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2905
Mailing Address - Country:US
Mailing Address - Phone:201-569-1332
Mailing Address - Fax:201-567-5955
Practice Address - Street 1:40 ENGLE ST
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2905
Practice Address - Country:US
Practice Address - Phone:201-569-1332
Practice Address - Fax:201-567-5955
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QL0900XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyLaboratory Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ4622201Medicaid
NJ303611Medicare ID - Type Unspecified
NJ4622201Medicaid