Healthcare Provider Details

I. General information

NPI: 1942257878
Provider Name (Legal Business Name): MICHAEL POLITES CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 SE GATE DR
CHERRY HILL NJ
08003-2636
US

IV. Provider business mailing address

104 SE GATE DR
CHERRY HILL NJ
08003-2636
US

V. Phone/Fax

Practice location:
  • Phone: 856-304-2962
  • Fax: 856-428-2878
Mailing address:
  • Phone: 856-304-2962
  • Fax: 856-428-2878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number26NR08913100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: