Provider Demographics
NPI:1285013474
Name:PAUL W MACELLARI PHD PC
Entity Type:Organization
Organization Name:PAUL W MACELLARI PHD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:MACELLARI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:574-254-9200
Mailing Address - Street 1:139 RED COACH DRIVE
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-3145
Mailing Address - Country:US
Mailing Address - Phone:574-254-9200
Mailing Address - Fax:574-254-9202
Practice Address - Street 1:135 RED COACH DR
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3145
Practice Address - Country:US
Practice Address - Phone:574-254-9200
Practice Address - Fax:574-254-9202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040273103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN235280Medicare PIN