Healthcare Provider Details

I. General information

NPI: 1033171020
Provider Name (Legal Business Name): NICHOLAS G. MELILLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 JAMES ST
EDISON NJ
08820-3945
US

IV. Provider business mailing address

2 LINCOLN HWY STE 302
EDISON NJ
08820-3904
US

V. Phone/Fax

Practice location:
  • Phone: 732-906-0091
  • Fax: 732-906-0249
Mailing address:
  • Phone: 732-906-0091
  • Fax: 732-906-0249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number25MA03774600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number25MA03774600
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier222955187
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerTAX ID
# 2
Identifier1824902
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer
# 3
Identifier203711560
Identifier TypeOTHER
Identifier StateNJ
Identifier IssuerTAX ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: