1548261605 NPI number — STEVEN D MELLUL D.O., FACS

Table of content: STEVEN D MELLUL D.O., FACS (NPI 1548261605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548261605 NPI number — STEVEN D MELLUL D.O., FACS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MELLUL
Provider First Name:
STEVEN
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
D.O., FACS
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:
1548261605
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
525 ROUTE 73 S
Provider Second Line Business Mailing Address:
SUITE 305
Provider Business Mailing Address City Name:
MARLTON
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08053-9642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-334-8227
Provider Business Mailing Address Fax Number:
856-334-8230

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 ROUTE 73 S
Provider Second Line Business Practice Location Address:
SUITE 305
Provider Business Practice Location Address City Name:
MARLTON
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08053-9642
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-334-8227
Provider Business Practice Location Address Fax Number:
856-334-8230
Provider Enumeration Date:
08/10/2005

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: 207W00000X , with the licence number:  MB07476600 , 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: 0018198 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 070943TIA . This is a "MEDICARE PTAN" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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