1710969597 NPI number — MICHAEL R LORELLO P.A.

Table of content: MICHAEL R LORELLO P.A. (NPI 1710969597)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710969597 NPI number — MICHAEL R LORELLO P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LORELLO
Provider First Name:
MICHAEL
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.A.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710969597
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10900 W 44TH AVE UNIT 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHEAT RIDGE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80033-2742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
720-548-1194
Provider Business Mailing Address Fax Number:
303-423-7004

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3890 TAMPA RD
Provider Second Line Business Practice Location Address:
SUITE 3404
Provider Business Practice Location Address City Name:
PALM HARBOR
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34684-3676
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-216-0505
Provider Business Practice Location Address Fax Number:
727-789-8261
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  C5-0012026 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 25MP00052700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: MA002676L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: PA9101788 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 291311900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 105923500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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