Provider Demographics
NPI:1134198724
Name:LICHARDI, MICHAEL L (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:L
Last Name:LICHARDI
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:L
Other - Last Name:LICHARDI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM, PA-C
Mailing Address - Street 1:2 STILLWELL PL
Mailing Address - Street 2:
Mailing Address - City:FREEHOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:07728-2022
Mailing Address - Country:US
Mailing Address - Phone:732-577-8340
Mailing Address - Fax:
Practice Address - Street 1:1925 PACIFIC AVENUE
Practice Address - Street 2:ATLANTICARE REGIONAL MEDICAL CENTER
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401
Practice Address - Country:US
Practice Address - Phone:732-407-1939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00119100363A00000X
NY2697363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ088138TDAMedicare ID - Type UnspecifiedPHYSICIAN ASSISTANT
NJU17242Medicare UPIN