=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598389330
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. MICHAEL KRECKEL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2020
-----------------------------------------------------
Last Update Date | 06/07/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1175 DEHIRSCH AVE
-----------------------------------------------------
City | WOODBINE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08270-2401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-471-4658
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 103 E POPLAR AVE UNIT 1C
-----------------------------------------------------
City | WILDWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08260-5249
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 40QA01793300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------