1235191875 NPI number — MICHAEL J. FELICETTA

Table of content: MICHAEL J. FELICETTA (NPI 1235191875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235191875 NPI number — MICHAEL J. FELICETTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FELICETTA
Provider First Name:
MICHAEL
Provider Middle Name:
J.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1235191875
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
54 BEY LEA RD
Provider Second Line Business Mailing Address:
STE 1
Provider Business Mailing Address City Name:
TOMS RIVER
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08753-2978
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-505-9728
Provider Business Mailing Address Fax Number:
732-505-9787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1178 ROUTE 37 W
Provider Second Line Business Practice Location Address:
STE 1
Provider Business Practice Location Address City Name:
TOMS RIVER
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08755-4920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-240-5677
Provider Business Practice Location Address Fax Number:
732-240-0926
Provider Enumeration Date:
04/06/2006

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: 213ES0131X , with the licence number:  MD00111300 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0990906 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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