Basic Information
| Provider Information | |||||||||
| NPI: | 1972569671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CALABRESE | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | LB # 7550 PO BOX 95000 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191957550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443621735 | ||||||||
| FaxNumber: | 9732907495 | ||||||||
| Practice Location | |||||||||
| Address1: | 328A SPARTA AVE | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9737292197 | ||||||||
| FaxNumber: | 9737293653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2006 | ||||||||
| LastUpdateDate: | 11/05/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MA050799 | NJ | Y | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD044378L | PA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 089309 | 05 | NJ | MEDICAID |