1134302946 NPI number — RICHARD L. MICCO, D.P.M.P.C.

Table of content: (NPI 1134302946)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134302946 NPI number — RICHARD L. MICCO, D.P.M.P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICHARD L. MICCO, D.P.M.P.C.
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:
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:
1134302946
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1612 W STATE ST # PA
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW CASTLE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16101-1246
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1612 W STATE ST # PA
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW CASTLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16101-1246
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-658-8589
Provider Business Practice Location Address Fax Number:
724-658-8978
Provider Enumeration Date:
12/14/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MICCO
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
724-658-8589

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  SC002758L , 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)