Provider Demographics
NPI:1659442374
Name:MOSCHELLA, MICHAEL G (CPO)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:G
Last Name:MOSCHELLA
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07017-1208
Mailing Address - Country:US
Mailing Address - Phone:973-736-2244
Mailing Address - Fax:973-736-2227
Practice Address - Street 1:331 MAIN ST
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017-1208
Practice Address - Country:US
Practice Address - Phone:973-736-2244
Practice Address - Fax:973-736-2227
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ45PO00013100335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3K4056OtherHEALTHNET
NJ8745501Medicaid
NJ2900665OtherAETNA HEALTHCARE
NJ8745501Medicaid