Provider Demographics
NPI:1790768125
Name:MARCHESE, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MARCHESE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 ROUTE 70
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-5940
Mailing Address - Country:US
Mailing Address - Phone:732-901-7314
Mailing Address - Fax:732-901-5704
Practice Address - Street 1:900 ROUTE 70
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5940
Practice Address - Country:US
Practice Address - Phone:732-901-7314
Practice Address - Fax:732-901-5704
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA047955002085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0585700Medicaid
NJ432022246OtherNJ BCBS
NJP624533OtherNJ OXFORD HEALTH PLANS
NJ2265396000OtherNJ AMERIHEALTH
NJ2K5010OtherNJ ACS/HEALTHNET
NJ400319OtherNJ GHI
NJ6332200Medicaid
NJD18754Medicare UPIN
NJ6332200Medicaid
NJ2K5010OtherNJ ACS/HEALTHNET
NJP00100395Medicare ID - Type UnspecifiedNJ RAILROAD MEDICARE