Basic Information
| Provider Information | |||||||||
| NPI: | 1023045028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | D'AMBROSIO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 858 | ||||||||
| Address2: | MC A410 | ||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170330858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002431455 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 500 UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | HERSHEY | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170332360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175318955 | ||||||||
| FaxNumber: | 7175314587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 12/03/2018 | ||||||||
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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 | 207P00000X | MB54553 | NJ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | OS009794L | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2410907 | 05 | NJ | MEDICAID | 0070357140002 | 05 | PA | MEDICAID |