Provider Demographics
NPI:1023045028
Name:D'AMBROSIO, MICHAEL R (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:D'AMBROSIO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:500 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2360
Practice Address - Country:US
Practice Address - Phone:717-531-8955
Practice Address - Fax:717-531-4587
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB54553207P00000X
PAOS009794L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2410907Medicaid
PA0070357140002Medicaid
NJ615105Medicare ID - Type Unspecified