=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174736193
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE CORRALES MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2007
-----------------------------------------------------
Last Update Date | 08/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 235 SHORE RD SUITE C
-----------------------------------------------------
City | SOMERS POINT
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08244-2631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-926-9400
-----------------------------------------------------
Fax | 609-926-4177
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 TRYENS DR
-----------------------------------------------------
City | MAYS LANDING
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08330-4912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 551-208-1778
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 25MA008278200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------