Provider Demographics
NPI:1134125412
Name:TEPPER, NELLY GISELLY (MD)
Entity Type:Individual
Prefix:
First Name:NELLY
Middle Name:GISELLY
Last Name:TEPPER
Suffix:
Gender:F
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:PO BOX 819
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15907-0819
Mailing Address - Country:US
Mailing Address - Phone:724-676-4691
Mailing Address - Fax:724-676-4697
Practice Address - Street 1:1743 GOUCHER ST
Practice Address - Street 2:
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-1205
Practice Address - Country:US
Practice Address - Phone:814-255-0102
Practice Address - Fax:814-255-0100
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD059706L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G32487Medicare UPIN
PA883775SKXMedicare ID - Type Unspecified