Provider Demographics
NPI:1255492963
Name:NOSSULI, TARECK O (MD)
Entity Type:Individual
Prefix:
First Name:TARECK
Middle Name:O
Last Name:NOSSULI
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:217 HARRISBURG AVE
Mailing Address - Street 2:THE HEART GROUP OF LGHEALTH
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-2964
Mailing Address - Country:US
Mailing Address - Phone:717-544-8300
Mailing Address - Fax:717-544-8265
Practice Address - Street 1:217 HARRISBURG AVE
Practice Address - Street 2:THE HEART GROUP OF LGHEALTH
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-2964
Practice Address - Country:US
Practice Address - Phone:717-544-8300
Practice Address - Fax:717-544-8265
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MA230421207R00000X
PAMD442547207RC0000X, 207RA0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0001XAllopathic & Osteopathic PhysiciansInternal MedicineAdvanced Heart Failure and Transplant Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1026033660001Medicaid
PA220678Medicare PIN