1679662712 NPI number — DR. MICHELLE G FESTA MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679662712 NPI number — DR. MICHELLE G FESTA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FESTA
Provider First Name:
MICHELLE
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
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:
1679662712
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60447
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-0447
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9955 POPLAR TENT RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28027-9314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-316-1161
Provider Business Practice Location Address Fax Number:
704-316-1162
Provider Enumeration Date:
10/12/2006

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: 207Q00000X , with the licence number:  MD047711L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MA60114 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 2022-00748 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6672396 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0713315000 . This is a "AMERIHEALTH HMO, KESYSTONE, IBC" identifier . This identifiers is of the category "OTHER".
  • Identifier: 010002623 . This is a "AMERICHOICE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 6462804 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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