1154558245 NPI number — DR. STEFANO MATTHEW MILITELLO D.P.M.

Table of content: DR. STEFANO MATTHEW MILITELLO D.P.M. (NPI 1154558245)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154558245 NPI number — DR. STEFANO MATTHEW MILITELLO D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MILITELLO
Provider First Name:
STEFANO
Provider Middle Name:
MATTHEW
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
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:
1154558245
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17900 23 MILE RD
Provider Second Line Business Mailing Address:
STE 204
Provider Business Mailing Address City Name:
MACOMB
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48044-1161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-948-9417
Provider Business Mailing Address Fax Number:
586-846-3910

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17900 23 MILE RD
Provider Second Line Business Practice Location Address:
STE 204
Provider Business Practice Location Address City Name:
MACOMB
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48044-1161
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-948-9417
Provider Business Practice Location Address Fax Number:
586-846-3910
Provider Enumeration Date:
06/16/2009

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: 213E00000X , with the licence number:  5901002316 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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