1306931092 NPI number — MICHELLE A IAVICOLI MD

Table of content: MICHELLE A IAVICOLI MD (NPI 1306931092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306931092 NPI number — MICHELLE A IAVICOLI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
IAVICOLI
Provider First Name:
MICHELLE
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1306931092
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 FEDERAL ST # 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMDEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08103-1088
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-356-4924
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1103 KINGS HWY N
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
CHERRY HILL
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08034-1983
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-321-1800
Provider Business Practice Location Address Fax Number:
856-321-0133
Provider Enumeration Date:
10/04/2006

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: 207V00000X , with the licence number:  MA58121 , 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: 1163594 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2067761 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 010003803 . This is a "AMERICHOICE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 160055209 . This is a "RR MEDICARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 24630 . This is a "UNIVERSITY HEALTH PLAN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 3K6126 . This is a "HEALTHNET" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 783367 . This is a "AMERIHEALTH PPO/PA BS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 783367 . This is a "PA BS HIGHMARK" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1078883 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2207020 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2542331 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7615001 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: JP131 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0809776000 . This is a "AMERIHEALTH/KEYSTONE/IBC" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2051479 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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