Provider Demographics
NPI:1184675274
Name:CONSALVO, JOHN A (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
Last Name:CONSALVO
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 1:2000 GREEN RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-1598
Mailing Address - Country:US
Mailing Address - Phone:734-995-3764
Mailing Address - Fax:
Practice Address - Street 1:1400 MAIN ST
Practice Address - Street 2:
Practice Address - City:PECKVILLE
Practice Address - State:PA
Practice Address - Zip Code:18452-2009
Practice Address - Country:US
Practice Address - Phone:570-489-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025156E207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009688010014Medicaid
PA0041657000OtherINDEPENDENCE BC
PA414646OtherHIGHMARK BS
PA0009688010014Medicaid
PA414646L9EMedicare PIN