Graduate Medical Education
Phone: (856) 566-7121
Fax: (856) 566-6222
One Medical Center Drive
Academic Center Suite 162
Stratford, NJ 08084-1501
Osteopathic Postdoctoral
Training Institution
Phone: (856) 566-7121
Fax: (856) 566-6222
**************************************************************
NOTE: This is the short version of the residency/fellowship application. This application is to be
completed if you are currently a PGY I in a UMDNJ-SOM OPTI program and will continue in a
UMDNJ-SOM OPTI residency program; will transfer from one UMDNJ-SOM OPTI residency
program to another UMDNJ-SOM OPTI residency program; or will enter a UMDNJ-SOM OPTI
fellowship program upon completion of a UMDNJ-SOM OPTI residency program. All other
applicants must complete the long version of the residency/fellowship application.
**************************************************************
Dear Doctor:
Attached is an application for residency and fellowship programs. This application is used for the UMDNJSOM OPTI residency and fellowship programs at Kennedy University Hospitals/Our Lady of Lourdes
Medical Center, and the Family Medicine Residency Program at Christ Hospital.
Please submit all information to the appropriate Program Director's office. Names, addresses, and phone
numbers for the residency and fellowship Program Directors are on the accompanying pages. Please check
with the program for deadline dates and available positions. To be considered for a residency or fellowship
program, please send the following to the Program Director's Office as soon as possible:
1.
Completed application (typed or printed legibly in black ink)
2.
Official medical school transcript
3.
Part I, II, and III Board scores
4.
Three (3) current letters of recommendation (if required by residency/fellowship program)
5.
Copy of contract from internship year
6.
Copy of internship and/or residency certificates
7.
Copy of any state license (if applicable)
8.
Copy of CDS and DEA certifications
Should you have any questions, please call the Program Director's Assistant at the number listed on the
accompanying pages.
Sincerely,
Joanne Kaiser-Smith, D.O., FACOI, FACP
Assistant Dean, Graduate Medical Education
Education
P.S. Visit us on the web at http://som.umdnj.edu
9/11 ss
Terry Brown, M.A.
Director,
Graduate
Medical
APPLICATION FOR RESIDENCY/FELLOWSHIP TRAINING
UMDNJ-School of Osteopathic Medicine
Osteopathic Postdoctoral Training Institution
Application for Residency/Fellowship in ___________________________________________________________
For Osteopathic Medical Education Year (i.e., OGME 2, 3)_____________ beginning July, __________________
PLEASE TYPE OR PRINT CLEARLY IN BLACK INK.
Name _______________________________________________________________________________________
(Last)
(First)
(Middle)
Social Security No. __________________________________
Present Address
AOA No. __________________________
_____________________________________ Phone (________) _________________
______________________________________________ Zip ____________________
Permanent Address
_____________________________________ Phone (________) _________________
______________________________________________ Zip ____________________
E-Mail Address
Emergency Contact _________________________________________
Address
_________________________________________________________________________________
Phone: Day (__________)_________________
Night (__________)_________________
Are you a: _____ U.S. Citizen? _____ Permanent Resident? _____Other?*
* If other, please provide documentation for eligibility to be employed in the U.S.
Pre-Professional Education: List, in order, Colleges or Universities you have attended.
Name of College
Dates of
Attendance
Location
Degree
and Date
____________________________________________________________________________________________
____________________________________________________________________________________________
Professional Education: List medical school(s) you attended.
Name of Medical School
Dates of
Attendance
Location
Degree
and Date
____________________________________________________________________________________________
____________________________________________________________________________________________
Post-Graduate Education:
Internship: Track ___________________________
Dates ______/_____/______ to ______/_____/______
Institution
City: _____________________ State: ____________
7/10 –tb
_______________________________
1 of 4
Post-Graduate Education (continued):
Residency: Specialty ________________________
Dates ______/_____/______ to ______/_____/______
Institution
City: _____________________ State: ____________
_______________________________
National Board of Osteopathic Medical Examiners board scores (COMLEX):
Part I
__________________
Date of Examination __________________________
Part II
__________________
Date of Examination __________________________
Part III
__________________
Date of Examination __________________________
Do you plan on taking the USMLE? ______No
______ Yes, Date of Exam _______________
New Jersey Medical License Number ___________________________________
New Jersey CDS Number: _________________
Federal DEA Registration Number: ____________________
Has your New Jersey medical license, New Jersey CDS or Federal DEA ever been suspended or revoked?
Yes ____________
No ____________
If yes, please explain: __________________________________________________________________
Do you have a license to practice medicine in any other state(s)? Yes _________
No _________
If yes, list states, dates and license numbers.
State
Dates
License Number
____________________________________________________________________________________________
____________________________________________________________________________________________
Have you ever been involved in a malpractice suit? Yes ____________ No ____________
If yes, please give the date and nature of case(s) and status of the suit, i.e. open, dismissed, closed with payment.
Date
Nature of Case
____________________________________________________________________________________________
____________________________________________________________________________________________
7/10 - tb
2 of 4
The Assistant Dean for Graduate Medical Education is the only authorized person who can offer letters of
acceptance or contracts to any of our residency or fellowship programs. Any other offer letters or contracts will not
be recognized by the University of Medicine and Dentistry of New Jersey – School of Osteopathic Medicine or any
of its affiliated programs or hospitals.
Your signature below indicates that you have completed this application in good faith and all answers are complete
and honest. You also understand that no one other than the Assistant Dean for Graduate Medical Education at
UMDNJ-SOM is authorized to make offers of acceptance or issue contracts to our programs.
_______________________________________________________
(Applicant's Signature)
____________________________
(Date)
________________________________________________________
(Print Name)
UMDNJ does not discriminate in admissions or access to its programs and activities on the
basis of race/color, national origin, ethnicity, religion/creed, disability, age, marital status,
sex, sexual orientation or veteran’s status.
Appointment to this position requires that you are not listed by the Office of Inspector
General (OIG) and/or the General Services Administration (GSA) as excluded from
participating in federal health care, research, or other grant programs.
8/09 - tb
3 of 4
UMDNJ-School of Osteopathic Medicine
Osteopathic Postdoctoral Training Institution
AUTHORIZATION FOR RELEASE OF INFORMATION AND
RELEASE FROM CIVIL LIABILITY
I specifically authorize the University and its authorized representatives to consult with the management and
members of the medical staffs of other hospitals, health care facilities, previous colleges/universities and/or other
institutions with which I have been associated and with others who may have information bearing on my professional
qualifications, credentials, clinical competence, character, mental or emotional stability, physical condition, ethics,
behavior, or any other matter. This University or its authorized representatives may inquire and inspect all records
and documents that may be material to the above.
I hereby release from civil liability any individual or institution reviewing or providing information relative to my
application for residency/fellowship at UMDNJ-SOM OPTI.
_______________________________________________________
(Applicant's Signature)
_______________________________________________________
(Print Name)
4 of 4
7/10 – tb
____________________________
(Date)
FELLOWSHIP PROGRAM DIRECTORS/COORDINATORS
CARDIOLOGY
John Hamaty, D.O.
cardiologyfellowship@sjhg.org
53 Kresson Road
Cherry Hill, NJ 08034
Attn: Kate Jurman
Email: cardiologyfellowship@sjhg.org
Phone: 856-755-1173
Fax: 856-667-6588
GASTROENTEROLOGY
John Chiesa, D.O.
chiesajo@umdnj.edu
University Doctors Pavilion
42 E. Laurel Road, #3100
Stratford, NJ 08084
Attn: Karen Welding-Brown
weldinkm@umdnj.edu
Phone: 856-566-2753
Fax: 856-566-6906
GERIATRICS (Pysch)
Stephen M. Scheinthal, D.O.
scheinth@umdnj.edu
University Doctors Pavilion
42 E. Laurel Road, #1800
Stratford, NJ 08084
Attn: Susan Huff
huffsm@umdnj.edu
Phone: 856-566-6124
Fax: 856-566-6419
ONCOLOGY
H. Timothy Dombrowski, D.O.
dombroht@umdnj.edu
University Doctors Pavilion
42 E. Laurel Road, #3100
Stratford, NJ 08084
Attn: Karen Welding-Brown
weldinkm@umdnj.edu
Phone: 856-566-2753
Fax: 856-566-6906
CRITICAL CARE
T BA
University Doctors Pavilion
42 E. Laurel Rd., #3100
Stratford, NJ 08084
Attn: Karen Welding-Brown
weldinkm@umdnj.edu
Phone: 856-566-2753
Fax: 856-566-6906
GERIATRICS (Family)
Kevin Overbeck, D.O.
overbeke@umdnj.edu
University Doctors Pavilion
42 E. Laurel Road, #1800
Stratford, NJ 08084
Attn: Susan Huff
huffsm@umdnj.edu
Phone: 856-566-6124
Fax: 856-566-6419
INFECTIOUS DISEASES
David Condoluci, D.O.
dcondoluci@gsida.org
709 Haddonfield-Berlin Road
Voorhees, NJ 08043
Attn: Marlene Folino
mfolino@gsida.org
Phone:856-566-3190 Ext. 330
Fax: 856-566-1903
ENDOCRINOLOGY
Louis Haenel, D.O.
endooffice05@yahoo.com
25 E. Laurel Rd.
Stratford, NJ 08084
Attn: Vicki Harvey
OMM
Milicent King Channell, D.O.
kingmi@umdnj.edu
University Doctors Pavilion
42 E. Laurel Road, #3900
Stratford, NJ 08084
Attn: Kathy Kupiec
kupieckl@umdnj.edu
Phone: 856-566-2877
Fax: 856-566-6385
PSYCHIATRY (Child)
Mark Sacher, D.O.
sachersm@umdnj.edu
2250 Chapel Avenue West, #100
Cherry Hill, NJ 08002
Attn: Elaine Evans
evansee@umdnj.edu
Phone: 856-482-9000
Fax: 856-482-1159
PULMONARY
James C. Giudice, D.O.
giudicje@umdnj.edu
University Doctors Pavilion
42 E. Laurel Road, #3100
Stratford, NJ 08084
Attn: Karen Welding-Brown
weldinkm@umdnj.edu
Phone: 856-566-2753
Fax: 856-566-6906
SLEEP MEDICINE
Amita Vasoya, M.D.
vasoyaam@umdnj.edu
University Doctors Pavilion
42 E. Laurel Road, Suite 3100
Stratford, NJ 08084
Attn: Karen Welding-Brown
weldinkm@umdnj.edu
Phone: 856-566-2753
Fax: 856-566-6906
endooffice05@yahoo.com
Phone: 856-783-2664
Fax: 856-783-8537
GERIATRICS (IM)
Terrie Ginsberg, D.O.
ginsbete@umdnj.edu
University Doctors Pavilion
42 E. Laurel Road, #1800
Stratford, NJ 08084
Attn: Susan Huff
huffsm@umdnj.edu
Phone: 856-566-6124
Fax: 856-566-6419
NEPHROLOGY
Joseph Pitone, D.O.
j.pitone@kennedyhealth.org
201 Laurel Oak Road
Voorhees, NJ 08043
Attn: Lynda Dunn
ldunn@NephNJ.com
Phone: 856-566-5478
Fax: 856-566-9561
RESIDENCY PROGRAM DIRECTORS / COORDINATORS
EMERGENCY MEDICINE
ENT –(Otorhinolaryngology)
FAMILY MEDICINE
Anthony J. DiPasquale, D.O.
anthonydipasquale@hotmail.com
Victor Scali, D.O.
scalicus@comcast.net
Kennedy Memorial Hospital
Administrative Office
18 E. Laurel Road
Stratford, NJ 08084
Attn: Susan Riser
Edward Scheiner, D.O.
e.scheiner@comcast.net
1924 East Rt. 70
Cherry Hill, NJ 08003
Attn: Linda Hendrickson
Lhendr6607@aol.com
Phone: 856-424-9200
Fax: 856-424-9245
George Scott, D.O.
gscott@umdnj.edu
University Doctors Pavilion
42 E. Laurel Road, #2100A
Stratford, NJ 08084
Attn: Amy Burnley
burnleal@umdnj.edu
Phone: 856-566-6477
Fax: 856-566-6360
INTERNAL MEDICINE
OB-GYN
Ricardo Perez, D.O., J.D.
perezri@umdnj.edu
University Doctors Pavilion
42 E. Laurel Road, #3100
Stratford, NJ 08084
Attn: Karen Welding-Brown
weldinkm@umdnj.edu
Phone: 856-566-2753
Fax: 856-566-6952
Michele Tartaglia, D.O.
michele22@juno.com
University Doctors Pavilion
42 E. Laurel Road, #3600
Stratford, NJ 08084
Attn: Naomi Spina
spinanr@umdnj.edu
Phone: 856-566-7098
Fax: 856-566-6499
ORTHOPEDIC
SURGERY
PSYCHIATRY
SURGERY – (General)
UROLOGY
Douglas Leonard, D.O.
leonardm@umdnj.edu
2250 Chapel Avenue, #100
Cherry Hill, NJ 08002
Attn: Elaine Evans
evansee@umdnj.edu
Phone: 856-482-9000
Fax: 856-566-1159
Alejandro Gandsas, M.D.
gandsaal@umdnj.edu
University Doctors Pavilion
42 E. Laurel Road, #2600
Stratford, NJ 08084
Attn: Colleen Corsetti
corsetco@umdnj.edu
Phone: 856-566-6875
Fax: 856-566-6873
Gordon Brown, D.O.
gbea94@aol.com
University Doctors Pavilion
42 E. Laurel Road, #2600
Stratford, NJ 08084
Attn: Maritza Rodriquez
rodrima@umdnj.edu
Phone: 856-566-6946
Fax: 856-566-6438
s.riser@kennedyhealth.org
Phone: 856-346-7985
Fax: 856-346-6573
Carl Mogil, D.O.
mogilca@umdnj.edu
University Doctors Pavilion
42 E. Laurel Road, #3900
Stratford, NJ 08084
Attn: Kathy Kupiec
kupieckl@umdnj.edu
Phone: 856-566-2877
Fax: 856-566-6385
IM/EM – Internal Medicine/Emergency Medicine
Internal Medicine:
Thomas Morley, D.O.
morleytf@umdnj.edu
University Doctors Pavilion
42 E. Laurel road, #3100
Stratford, NJ 08084
Attn: Karen Welding-Brown
weldinkm@umdnj.edu
Phone: 856-566-2753
Fax: 856-566-6952
Emergency Medicine:
Victor Scali, D.O.
scalicus@comcast.net
Kennedy Memorial Hospital
Administrative Office
18 E. Laurel Road
Stratford, NJ 08084
Attn: Susan Riser
s.riser@kennedyhealth.org
Phone: 856-566-7985
Fax: 856-566-6573