Provider Demographics
NPI:1275538365
Name:SALLY, ALAN C (DPM)
Entity Type:Individual
Prefix:DR
First Name:ALAN
Middle Name:C
Last Name:SALLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631A NATIONAL PIKE E
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15417-9603
Mailing Address - Country:US
Mailing Address - Phone:724-785-8060
Mailing Address - Fax:724-785-6217
Practice Address - Street 1:631A NATIONAL PIKE E
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:PA
Practice Address - Zip Code:15417
Practice Address - Country:US
Practice Address - Phone:724-785-8060
Practice Address - Fax:724-785-6217
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2018-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002363L213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008700630003Medicaid
PAT28169Medicare UPIN
PA0008700630003Medicaid