Basic Information
| Provider Information | |||||||||
| NPI: | 1144269614 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARAVENTANO | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | F. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 E PENN SQ | ||||||||
| Address2: | 9TH FL | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191073323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2674259258 | ||||||||
| FaxNumber: | 2674259299 | ||||||||
| Practice Location | |||||||||
| Address1: | 175 MADISON AVE | ||||||||
| Address2: | CHOP CARE NETWORK @VIRTUA MEMORIAL HOSPITAL | ||||||||
| City: | MOUNT HOLLY | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080602038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6099146226 | ||||||||
| FaxNumber: | 6092615842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2006 | ||||||||
| LastUpdateDate: | 11/03/2014 | ||||||||
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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 | 208000000X | 25MA07749200 | NJ | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | MD421934 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 208000000X | MD421934 | PA | N | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | 25MA07749200 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0044270 | 05 | NJ | MEDICAID | 2416654000 | 01 | NJ | AMERIHEALTH | OTHER |