1871656009 NPI number — PETER VASSALLUZZO D.O.

Table of content: (NPI 1871656009)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871656009 NPI number — PETER VASSALLUZZO D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PETER VASSALLUZZO D.O.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LAWNDALE MEDICAL ASSOCIATES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871656009
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6190 RISING SUN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19111-6011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-725-8111
Provider Business Mailing Address Fax Number:
215-742-9501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6190 RISING SUN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19111-6011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-725-8111
Provider Business Practice Location Address Fax Number:
215-742-9501
Provider Enumeration Date:
12/19/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
VASSALLUZZO
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
215-725-8111

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  OS-006575L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0543451000 . This is a "KEYSTONE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".