Basic Information
| Provider Information | |||||||||
| NPI: | 1306871033 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAZZELLA | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 S. E. CARY PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194674992 | ||||||||
| FaxNumber: | 9192970145 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 S. E. CARY PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194674992 | ||||||||
| FaxNumber: | 9192970145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 3168 | NC | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 07891 | 01 | NC | BCBS PROVIDER NUMBER | OTHER |