Provider Demographics
NPI:1235422759
Name:LYCEUM PHYSICAL MEDICINE, PC
Entity Type:Organization
Organization Name:LYCEUM PHYSICAL MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEZZELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:215-508-5555
Mailing Address - Street 1:6062 RIDGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128
Mailing Address - Country:US
Mailing Address - Phone:215-508-5555
Mailing Address - Fax:215-508-5554
Practice Address - Street 1:6062 RIDGE AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19128
Practice Address - Country:US
Practice Address - Phone:215-508-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-17
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208100000X
PAMD034915E208D00000X
PAMD032971E332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1137870Medicaid
PA1137870Medicaid
PAE76358Medicare UPIN