Basic Information
| Provider Information | |||||||||
| NPI: | 1447226261 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FANTASIA | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 NEW PROVIDENCE RD | ||||||||
| Address2: | |||||||||
| City: | MOUNTAINSIDE | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070922590 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9083015404 | ||||||||
| FaxNumber: | 9083015456 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 SOMERSET ST | ||||||||
| Address2: | |||||||||
| City: | NEW BRUNSWICK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 089011942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7322587000 | ||||||||
| FaxNumber: | 9083015456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 08/24/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P0010X | 25MA06336800 | NJ | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pediatric Rehabilitation Medicine |
ID Information
| ID | Type | State | Issuer | Description | 221487148 | 01 | NJ | DEVON HEALTHCARE | OTHER | 01000313201 | 01 | NJ | AMERICHOICE NJ | OTHER | 1096732 | 01 | NJ | HORIZON NJ HEALTH | OTHER | 2119078000 | 01 | NJ | AMERIHEALTH | OTHER | 221487148 | 01 | NJ | UNITED HEALTHCARE | OTHER | S51B01 | 01 | NJ | EMPIRE | OTHER | 0125682 | 01 | NJ | CIGNA HEALTHCARE | OTHER | P2122543 | 01 | NJ | OXFORD | OTHER | 2K3684 | 01 | NJ | HEALTHNET | OTHER | 54027 | 01 | NJ | AMERIGROUP | OTHER | 221487148 | 01 | NJ | MULTIPLAN | OTHER | 2300074 | 01 | NJ | AETNA HEALTHCARE | OTHER | 24225 | 01 | NJ | UNIVERSITY HEALTH PLAN | OTHER | 221487148 | 01 | NJ | GREAT WEST | OTHER | 221487148 | 01 | NJ | HORIZON BCBS NJ | OTHER | 221487148-016 | 01 | NJ | QUALCARE INC | OTHER |