Provider Demographics
NPI:1497783781
Name:CIVITELLO, MICHAEL (PT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:CIVITELLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:BELLE VERNON
Mailing Address - State:PA
Mailing Address - Zip Code:15012-1664
Mailing Address - Country:US
Mailing Address - Phone:724-929-5774
Mailing Address - Fax:724-929-9524
Practice Address - Street 1:812 BROAD AVE
Practice Address - Street 2:
Practice Address - City:BELLE VERNON
Practice Address - State:PA
Practice Address - Zip Code:15012-1664
Practice Address - Country:US
Practice Address - Phone:724-929-5774
Practice Address - Fax:724-929-9524
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT010031L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015935850006Medicaid
PA396610Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER