Provider Demographics
NPI:1336170638
Name:RESNICK, MICHAEL A (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:RESNICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:9501 ROOSEVELT BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-1025
Mailing Address - Country:US
Mailing Address - Phone:215-671-9900
Mailing Address - Fax:215-671-9110
Practice Address - Street 1:9501 ROOSEVELT BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1025
Practice Address - Country:US
Practice Address - Phone:215-671-9900
Practice Address - Fax:215-671-9110
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAOS003948L207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0086025401Medicaid
PA0086025401Medicaid
PA094158Medicare ID - Type Unspecified