Provider Demographics
NPI:1447789524
Name:CREDAROLI, ELLESSE (DO)
Entity Type:Individual
Prefix:DR
First Name:ELLESSE
Middle Name:
Last Name:CREDAROLI
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 1:3400 SPRUCE STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-4206
Mailing Address - Country:US
Mailing Address - Phone:215-349-8310
Mailing Address - Fax:215-893-7270
Practice Address - Street 1:3400 SPRUCE STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4206
Practice Address - Country:US
Practice Address - Phone:215-349-8310
Practice Address - Fax:215-893-7270
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-12
Last Update Date:2023-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS022704207L00000X
MA291137207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology