MEDICARE: DR. MICHELLE L. IACARUSO D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	25MB08365400	NJ
2	207Q00000X	Family Medicine Physician	OS009282L	PA

General Provider Information

NPI Number	:	1083673784
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHELLE L. IACARUSO D.O.

Provider Business Mailing Address
First Line	:	39 OLCOTT SQ
Second Line	:
City	:	BERNARDSVILLE
State	:	NJ
Zip	:	07924-2317
Country	:	US
Telephone Number	:	908-221-1919
Fax Number	:	908-221-1005

Provider Business Practice Location Address
First Line	:	39 OLCOTT SQ
Second Line	:
City	:	BERNARDSVILLE
State	:	NJ
Zip	:	07924-2317
Country	:	US
Telephone Number	:	908-221-1919
Fax Number	:	908-221-1005

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/21/2006
Last Update Date	:	03/19/2008

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