Provider Demographics
NPI:1114922648
Name:PELLICCIA, LANNY C (DPM)
Entity Type:Individual
Prefix:DR
First Name:LANNY
Middle Name:C
Last Name:PELLICCIA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 PIERCE ST
Mailing Address - Street 2:STE 301
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5141
Mailing Address - Country:US
Mailing Address - Phone:570-283-3668
Mailing Address - Fax:570-283-0309
Practice Address - Street 1:270 PIERCE ST
Practice Address - Street 2:STE 301
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5141
Practice Address - Country:US
Practice Address - Phone:570-283-3668
Practice Address - Fax:570-283-0309
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-21
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC-003688-L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U27800OtherHEALTH ASSURANCE
05152OtherEMPIRE BC/BS
232635090 001OtherTRICARE / CHAMPUS
4532974OtherAETNE / PPO
G09847OtherAMERIHEALTH
PA075903OtherFIRST PRIORITY HEALTH
611664OtherTRIGON / MEDIGAP
PAPE709847OtherBLUE CROSS / BLUE SHIELD
PA001285747/0002Medicaid
1502456OtherUNITED MINE WORKERS
PA26464OtherGEISINGER HEALTH PLAN
P3179662OtherOXFORD
150228OtherGATEWAY
0528845OtherAETNA / HMO
76219OtherMEDPLUS
PA001285747/0002Medicaid
232635090 001OtherTRICARE / CHAMPUS
0756710001Medicare NSC