1114922648 NPI number — DR. LANNY C PELLICCIA DPM

Table of content: DR. LANNY C PELLICCIA DPM (NPI 1114922648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114922648 NPI number — DR. LANNY C PELLICCIA DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PELLICCIA
Provider First Name:
LANNY
Provider Middle Name:
C
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1114922648
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
270 PIERCE ST
Provider Second Line Business Mailing Address:
STE 301
Provider Business Mailing Address City Name:
KINGSTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18704-5141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-283-3668
Provider Business Mailing Address Fax Number:
570-283-0309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
270 PIERCE ST
Provider Second Line Business Practice Location Address:
STE 301
Provider Business Practice Location Address City Name:
KINGSTON
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18704-5141
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-283-3668
Provider Business Practice Location Address Fax Number:
570-283-0309
Provider Enumeration Date:
06/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  SC-003688-L , 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: U27800 . This is a "HEALTH ASSURANCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 05152 . This is a "EMPIRE BC/BS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 232635090 001 . This is a "TRICARE / CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4532974 . This is a "AETNE / PPO" identifier . This identifiers is of the category "OTHER".
  • Identifier: G09847 . This is a "AMERIHEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 075903 . This is a "FIRST PRIORITY HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 611664 . This is a "TRIGON / MEDIGAP" identifier . This identifiers is of the category "OTHER".
  • Identifier: PE709847 . This is a "BLUE CROSS / BLUE SHIELD" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 001285747/0002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1502456 . This is a "UNITED MINE WORKERS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 26464 . This is a "GEISINGER HEALTH PLAN" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: P3179662 . This is a "OXFORD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 150228 . This is a "GATEWAY" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0528845 . This is a "AETNA / HMO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 76219 . This is a "MEDPLUS" identifier . This identifiers is of the category "OTHER".




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