Provider Demographics
NPI:1235101932
Name:MICHAEL PICCARELLI DPM
Entity Type:Organization
Organization Name:MICHAEL PICCARELLI DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SELF PROPRIETER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PICCARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-273-0123
Mailing Address - Street 1:1478 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3915
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1478 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3915
Practice Address - Country:US
Practice Address - Phone:718-273-0123
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006042213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYV02473Medicare UPIN
NY5554800001Medicare NSC
NY06126MMedicare PIN