Provider Demographics
NPI:1265491633
Name:NEELY, EDWARD M (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:M
Last Name:NEELY
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 1:8702 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MOON TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:15108-4209
Mailing Address - Country:US
Mailing Address - Phone:412-299-3627
Mailing Address - Fax:412-299-3623
Practice Address - Street 1:8702 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:MOON TOWNSHIP
Practice Address - State:PA
Practice Address - Zip Code:15108-4209
Practice Address - Country:US
Practice Address - Phone:412-299-3627
Practice Address - Fax:412-299-3623
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22191207P00000X, 2083X0100X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC221913Medicaid
E1569OtherMEDCOST
AA07628163Medicare ID - Type Unspecified
E1569OtherMEDCOST