Provider Demographics
NPI:1407016736
Name:MENICHELLO, GINA (DO)
Entity Type:Individual
Prefix:DR
First Name:GINA
Middle Name:
Last Name:MENICHELLO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1111
Mailing Address - Street 2:
Mailing Address - City:HARLEYSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19438-0907
Mailing Address - Country:US
Mailing Address - Phone:215-453-4995
Mailing Address - Fax:215-453-4646
Practice Address - Street 1:700 HORIZON DR
Practice Address - Street 2:SUITE 103
Practice Address - City:CHALFONT
Practice Address - State:PA
Practice Address - Zip Code:18914-3967
Practice Address - Country:US
Practice Address - Phone:215-822-3130
Practice Address - Fax:215-822-3134
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS014574207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102315469Medicaid
PA157917Medicare PIN