Healthcare Provider Details

I. General information

NPI: 1003613217
Provider Name (Legal Business Name): MICHAEL STEPHEN RALLO MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2025
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 SPRUCE ST
PHILADELPHIA PA
19104-4238
US

IV. Provider business mailing address

208 IRONWOOD DR
WOODBURY NJ
08096-5569
US

V. Phone/Fax

Practice location:
  • Phone: 845-699-6932
  • Fax:
Mailing address:
  • Phone: 445-284-4464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT237344
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: