Provider Demographics
NPI:1043202294
Name:SANGILLO, MARIO M (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:M
Last Name:SANGILLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 W BAYBERRY DRIVE
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2025 TECHNOLOGY PKWY
Practice Address - Street 2:STE 108
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-9400
Practice Address - Country:US
Practice Address - Phone:717-791-2680
Practice Address - Fax:717-791-2688
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD026221E208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01464401OtherCAIC
PA0008697970006Medicaid
PASA054783OtherHIGHMARK BLUE SHIELD
PASA054783OtherHIGHMARK BLUE SHIELD