Basic Information
| Provider Information | |||||||||
| NPI: | 1528057353 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MICELI | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | KENNETH | ||||||||
| NamePrefix: | PROF. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 585 BROADWAY | ||||||||
| Address2: | BROADWAY INTERNAL MEDICINE ASSOCIATES P C | ||||||||
| City: | MASSAPEQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117585023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167971234 | ||||||||
| FaxNumber: | 5167971932 | ||||||||
| Practice Location | |||||||||
| Address1: | 585 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117585023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167971234 | ||||||||
| FaxNumber: | 5167971932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2005 | ||||||||
| LastUpdateDate: | 09/28/2007 | ||||||||
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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 | 207RI0011X | 130596 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 00409210 | 05 | NY | MEDICAID |