MEDICARE: DR. MICHAEL A MITACCHIONE DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	40QA00857500	NJ

General Provider Information

NPI Number	:	1043258569
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL A MITACCHIONE DPT

Provider Business Mailing Address
First Line	:	1 DIAMOND HILL RD
Second Line	:
City	:	BERKELEY HEIGHTS
State	:	NJ
Zip	:	07922-2104
Country	:	US
Telephone Number	:	908-273-4300
Fax Number	:

Provider Business Practice Location Address
First Line	:	899 MOUNTAIN AVE STE 2A
Second Line	:
City	:	SPRINGFIELD
State	:	NJ
Zip	:	07081-3403
Country	:	US
Telephone Number	:	908-228-3632
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	12/08/2020

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