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General NPI Number Information
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NPI Number | 1518901925
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Entity Type | Individual
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Provider Name | GREGORY BLASE PERSICHETTI D.O.
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Gender | Male
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Dates
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Enumeration Date | 06/15/2006
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Last Update Date | 12/03/2015
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Provider Practice Location Address
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Address Line | 100 KINGS WAY E SUITE A-3
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City | SEWELL
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State | NJ
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Zip | 08080-2237
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Country | US
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Telephone | 856-589-3331
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Fax | 856-589-3416
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Provider Business Mailing Address
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Address Line | 100 KINGS WAY E SUITE A-3
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City | SEWELL
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State | NJ
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Zip | 08080-2237
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Country | US
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Telephone | 856-589-3331
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Fax | 856-589-3416
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | 25MB08242000
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 207ND0101X
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Taxonomy Name | MOHS-Micrographic Surgery Physician
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License Number | 08012552
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License Number State | PA
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