Basic Information
Provider Information | |||||||||
NPI: | 1568469153 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SASSO | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2 EVES DR | ||||||||
Address2: | SUITE 109 | ||||||||
City: | MARLTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 080533193 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8566696061 | ||||||||
FaxNumber: | 8566510853 | ||||||||
Practice Location | |||||||||
Address1: | 338 HURFFVILLE CROSSKEYS RD | ||||||||
Address2: |   | ||||||||
City: | SEWELL | ||||||||
State: | NJ | ||||||||
PostalCode: | 080809202 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8565890600 | ||||||||
FaxNumber: | 8565897979 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2005 | ||||||||
LastUpdateDate: | 03/24/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 25MB04835000 | NJ | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 4586808 | 05 | NJ |   | MEDICAID |