Jack Facciolo, D.O.

Primary specialty

SpecialistTaxonomy code 174400000X

License

MB039210 Issued in NJ

Practice address

1 Secluded LN
Rio Grande, NJ 08242-1546

Phone

(609) 368-1952

NPI assigned

Mar 16, 2006

Last updated

Dec 1, 2009By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 6

Medicare fee-for-service enrollment

Enrolled in NJ

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Osteopathy

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1142467200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1259625600000",
    "number": "1558330076",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 SECLUDED LN",
            "city": "RIO GRANDE",
            "state": "NJ",
            "postal_code": "082421546",
            "telephone_number": "609-368-1952"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 SECLUDED LN",
            "city": "RIO GRANDE",
            "state": "NJ",
            "postal_code": "082421546",
            "telephone_number": "609-368-1952"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FACCIOLO",
        "first_name": "JACK",
        "name_prefix": "Dr.",
        "credential": "D.O.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-03-16",
        "last_updated": "2009-12-01",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "NJ",
            "license": "MB039210",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CIGNA HMO NUMBER",
            "identifier": "825040",
            "state": "NJ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "HORIZON NJ HEALTH NUMBER",
            "identifier": "1074056",
            "state": "NJ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "INDP BCBS PROVIDER NUMBER",
            "identifier": "0090462000",
            "state": "NJ"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2345005",
            "state": "NJ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "CIGNA PPO NUMBER",
            "identifier": "1213261003",
            "state": "NJ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "OXFORD PROVIDER NUMBER",
            "identifier": "CMS005",
            "state": "NJ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Joanne Lynn Dwyer, AU.D., M.S., CCC-A
• Easter Seals New Jersey
• Easter Seals New Jersey
• Amanda L Eller, MS, LSW, C-SSW
• Christina Esterly, CADC
• Nicole Sagan Farrell, M.A., LPC
• Antonio Figueroa, PA-C
• Diane Richardson Flannegan, LCSW
• Celiese Danielle Flitcroft, MSW, LSW
• Alecia Fox, NP

• Specialist in Rio Grande, NJ
• Providers in Rio Grande, NJ by specialty
• Specialist in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 1, 2009; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.