Provider Demographics
NPI:1710956073
Name:MICHELIS, MARY ANN E (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:E
Last Name:MICHELIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:360 ESSEX STREET
Mailing Address - Street 2:SUITE 302
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601
Mailing Address - Country:US
Mailing Address - Phone:551-996-2065
Mailing Address - Fax:551-996-2169
Practice Address - Street 1:360 ESSEX STREET
Practice Address - Street 2:SUITE 302
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601
Practice Address - Country:US
Practice Address - Phone:551-996-2065
Practice Address - Fax:551-996-2169
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA03935600207K00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD06349Medicare UPIN
NJ421139Medicare ID - Type Unspecified