Provider Demographics
NPI:1316155450
Name:MICELI, KURT P (MD)
Entity type:Individual
Prefix:DR
First Name:KURT
Middle Name:P
Last Name:MICELI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1255 CALDWELL RD
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08034-3220
Mailing Address - Country:US
Mailing Address - Phone:856-324-3256
Mailing Address - Fax:856-667-1281
Practice Address - Street 1:111 ELWYN RD
Practice Address - Street 2:
Practice Address - City:ELWYN
Practice Address - State:PA
Practice Address - Zip Code:19063-4622
Practice Address - Country:US
Practice Address - Phone:610-891-7385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4425742084P0800X
NJ25MA096358002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1316155450Medicaid