Healthcare Provider Details

I. General information

NPI: 1558320010
Provider Name (Legal Business Name): MICHELLE ELAINE MELICOSTA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2006
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N BROADWAY KENNEDY KRIEGER INSTITUTE
BALTIMORE MD
21205-1832
US

IV. Provider business mailing address

707 N BROADWAY KENNEDY KRIEGER INSTITUTE
BALTIMORE MD
21205-1832
US

V. Phone/Fax

Practice location:
  • Phone: 443-923-9446
  • Fax: 443-923-9445
Mailing address:
  • Phone: 443-923-9446
  • Fax: 443-923-9445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number153384
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0078581
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: