Basic Information
| Provider Information | |||||||||
| NPI: | 1740612548 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | COSTANZO | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 740 MARNE HWY | ||||||||
| Address2: | STE 203 | ||||||||
| City: | MOORESTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080573127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8569141400 | ||||||||
| FaxNumber: | 8562343014 | ||||||||
| Practice Location | |||||||||
| Address1: | 740 MARNE HWY | ||||||||
| Address2: | STE 203 | ||||||||
| City: | MOORESTOWN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080573127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8569141400 | ||||||||
| FaxNumber: | 8562343014 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2013 | ||||||||
| LastUpdateDate: | 06/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 40QA01535700 | NJ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | PT023071 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.