1770561490 NPI number — DR. SHANNON MARINIELLO DC

Table of content: DR. SHANNON MARINIELLO DC (NPI 1770561490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770561490 NPI number — DR. SHANNON MARINIELLO DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARINIELLO
Provider First Name:
SHANNON
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DC
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:
1770561490
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
517 RIVER DR STE 2A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GARFIELD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07026-3270
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-955-0755
Provider Business Mailing Address Fax Number:
973-955-0753

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
517 RIVER DR STE 2A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07026-3270
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-955-0755
Provider Business Practice Location Address Fax Number:
973-955-0753
Provider Enumeration Date:
01/03/2006

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: 111N00000X , with the licence number:  38MC00505700 , 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: 1996718 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 31356 . This is a "MASTERCARE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5899591 . This is a "GHI" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5936399004 . This is a "CIGNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: X2D241 . This is a "EMPIRE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1047999 . This is a "AETNA HMO" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 050005057NJ01 . This is a "ANTHEM HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 0798375000 . This is a "AMERIHEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 96301 . This is a "AMERIGROUP" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1126013 . This is a "HORIZON NJ HEALTH" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5362694 . This is a "AETNA" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 5362694 . This is a "AETNA PPO" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7722702 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 24878 . This is a "UNIVERSITY HEALTH PLANS" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P2084184 . This is a "OXFORD" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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