1194723007 NPI number — MARIO J. SEBASTIANELLI, MD PC

Table of content: (NPI 1194723007)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194723007 NPI number — MARIO J. SEBASTIANELLI, MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARIO J. SEBASTIANELLI, MD PC
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:
1194723007
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1416 MONROE AVE
Provider Second Line Business Mailing Address:
STE 206
Provider Business Mailing Address City Name:
DUNMORE
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18509-2477
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-347-5212
Provider Business Mailing Address Fax Number:
570-346-4814

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1416 MONROE AVE
Provider Second Line Business Practice Location Address:
STE 206
Provider Business Practice Location Address City Name:
DUNMORE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18509-2477
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-347-5212
Provider Business Practice Location Address Fax Number:
570-346-4814
Provider Enumeration Date:
07/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
SEBASTIANELLI
Authorized Official First Name:
MARIO
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
570-347-5212

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  MD006983E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: MD006983E , 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: 0669080 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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