Provider Demographics
NPI:1437180817
Name:CREDICO, MICHAEL M (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:CREDICO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2918
Mailing Address - Country:US
Mailing Address - Phone:973-338-3620
Mailing Address - Fax:973-338-4849
Practice Address - Street 1:1129 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2918
Practice Address - Country:US
Practice Address - Phone:973-338-3620
Practice Address - Fax:973-338-4849
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMC01570111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJT45228Medicare UPIN
NJ451849P5MMedicare ID - Type Unspecified